Forms & Policies
TLC Pediatrics of Amarillo, PA is an independent, self-owned and operated pediatric group. On this page, you’ll find information about our general office policies as well as links to some of the forms that you can print out and fill out before your appointment to save time.
Forms
To expedite the registration process and for your convenience several forms are made available in PDF format for printing and completion. You can download (using the free Adobe Reader software) and print out. Filling out these forms prior to your office visit can save you time. Please either print the blank forms and fill them out by hand, or simply fill out the forms electronically while online and then print your completed forms (clicking on the editable areas of the form will allow you to fill in your information).
Please send the completed forms to registration@drmaaytah.com
- Patient Information form
- Medical History & Insurance Information Form
- Responsible Party Statement
- Authorization and Consent Form
- HIPPA Acnowledgement
- Financial Policy Form
- Credit Card Charge Authorization
- Medical Record Release to TLC Pediatrics
- Medical Record Release from TLC Pediatrics
If you are unable to open the for please click here to get Adobe Reader:
Billing Policies & Forms
At TLC Pediatrics of Amarillo, we take pride in caring for children and truly value the close relationships we form with our patients and their families. Providing excellent care requires time, skill, and dedicated staff, and timely payment helps us continue to “be there” for your family whenever you need us. At TLC Pediatrics, our goal is to make the financial side of your child’s care as easy and transparent as possible. Thank you for your cooperation and for being part of our TLC family!
Billing Policies:
Below are our billing policies designed to make the process clear, fair, and convenient for everyone:
We require verification of your insurance and identification at every visit. Please inform us immediately of any changes to your insurance, address, or contact information. It is your responsibility to ensure your insurance policy with TLC Pediatrics remains active and current.
We will bill the insurance company you provide for all services. If we do not receive payment from your insurer within 60 days, the balance becomes your responsibility. You will be notified of any unpaid amounts.
If a balance remains unpaid 60 days after notification, we may need to reschedule routine checkups or non-urgent appointments until payment is resolved.
Balances over $10 may be charged to your Visa or MasterCard. To simplify billing, we encourage families to complete a Credit Card Authorization Form. Please print, fill out the form, and return it by mail, fax, or in person at your next appointment.
If your family is experiencing financial hardship, let us know. We’re happy to work with you to arrange a reasonable payment plan. Our priority is ensuring your child receives the care they need.
If a check is returned and does not clear on the second attempt, a $35 fee will be added to your account. After two returned checks, we will no longer accept checks from your family. All future payments must be made by credit card or cash.
Copayments, coinsurance, deductibles, and any charges not covered by insurance are due at the time of your visit. The adult accompanying the child is responsible for payment at the time of service.
If balances not covered by insurance remain unpaid after 60 days of notification, we may need to reschedule routine checkups until the account is settled.
Fees for forms or requested physician letters are due at the time of your request. Completed forms may be picked up at our office. If you’d prefer them mailed, please include a self-addressed stamped envelope.