{"id":195,"date":"2025-09-18T15:24:46","date_gmt":"2025-09-18T15:24:46","guid":{"rendered":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/?page_id=195"},"modified":"2025-10-14T06:33:20","modified_gmt":"2025-10-14T06:33:20","slug":"forms-policies","status":"publish","type":"page","link":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/forms-policies\/","title":{"rendered":"Forms &#038; Policies"},"content":{"rendered":"<p>[vc_section full_width=&#8221;stretch_row&#8221; content_placement=&#8221;middle&#8221; css=&#8221;.vc_custom_1760423196549{margin-top: px !important;padding-top: 50px !important;padding-bottom: 50px !important;background-color: #ffffff !important;}&#8221; el_class=&#8221;color-white-li&#8221;][vc_row content_placement=&#8221;middle&#8221;][vc_column width=&#8221;1\/2&#8243;][vc_single_image image=&#8221;476&#8243; img_size=&#8221;full&#8221; el_class=&#8221;about-img&#8221;][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text]<\/p>\n<h2><span style=\"color: #000000;\">Forms &amp; Policies<\/span><\/h2>\n<p><span style=\"color: #000000;\">TLC Pediatrics of Amarillo, PA is an independent, self-owned and operated pediatric group. On this page, you\u2019ll 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.<\/span><\/p>\n<h3><span style=\"color: #000000;\">Forms<\/span><\/h3>\n<p><span style=\"color: #000000;\">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).<\/span><\/p>\n<h3><span style=\"color: #000000;\">Please send the completed forms to\u00a0<a style=\"color: #000000;\" href=\"mailto:registration@drmaaytah.com\"><i class=\"fas fa-envelope-open-text\"><\/i>registration@drmaaytah.com<\/a><\/span><\/h3>\n<ul>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/patient-information-form\/\" target=\"_blank\" rel=\"noopener\"><u>Patient Information form<\/u><\/a><\/span><\/li>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/medical-history-insurance-information-form\/\" target=\"_blank\" rel=\"noopener\"><u>Medical History &amp; Insurance Information Form<\/u><\/a><\/span><\/li>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/responsible-party-statement\/\" target=\"_blank\" rel=\"noopener\"><u>Responsible Party Statement<\/u><\/a><\/span><\/li>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/authorization-and-consent-form\/\" target=\"_blank\" rel=\"noopener\"><u>Authorization and Consent Form<\/u><\/a><\/span><\/li>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-content\/uploads\/2025\/09\/HIPPA-Stat-1.pdf\" target=\"_blank\" rel=\"noopener\"><u>HIPPA Acnowledgement<\/u><\/a><\/span><\/li>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/financial-policy\/\" target=\"_blank\" rel=\"noopener\"><u>Financial Policy Form<\/u><\/a><\/span><\/li>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/credit-card-charge-authorization\/\" target=\"_blank\" rel=\"noopener\"><u>Credit Card Charge Authorization<\/u><\/a><\/span><\/li>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/medical-record-release-to-tlc-pediatrics\/\" target=\"_blank\" rel=\"noopener\"><u>Medical Record Release to TLC Pediatrics<\/u><\/a><\/span><\/li>\n<li><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/medical-record-release-from-tlc-pediatrics\/\" target=\"_blank\" rel=\"noopener\"><u>Medical Record Release from TLC Pediatrics<\/u><\/a><\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\">If you are unable to open the for please click here to get Adobe Reader:\u00a0<\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1760361737224{margin-top: 40px !important;}&#8221;][vc_column el_class=&#8221;color-white-li&#8221;][vc_column_text]<span style=\"color: #000000;\"><strong>Billing Policies &amp; Forms<\/strong><\/span><\/p>\n<p><span style=\"color: #000000;\">At <strong>TLC Pediatrics of Amarillo<\/strong>, 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 \u201cbe there\u201d for your family whenever you need us. At TLC Pediatrics, our goal is to make the financial side of your child\u2019s care as easy and transparent as possible. Thank you for your cooperation and for being part of our TLC family!<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"color: #000000;\"><strong>Billing Policies:<\/strong><\/span><\/p>\n<p><span style=\"color: #000000;\">Below are our billing policies designed to make the process clear, fair, and convenient for everyone:<\/span>[\/vc_column_text][vc_tta_accordion spacing=&#8221;20&#8243; gap=&#8221;20&#8243; active_section=&#8221;1&#8243;][vc_tta_section title=&#8221;Insurance Information&#8221; tab_id=&#8221;1760423238767-6c5b9830-eb7d&#8221;][vc_column_text]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.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Insurance Claims and Balances&#8221; tab_id=&#8221;1760423331631-37f6d98c-c6c8&#8243;][vc_column_text]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.<\/p>\n<p>&nbsp;<\/p>\n<p>If a balance remains unpaid 60 days after notification, we may need to reschedule routine checkups or non-urgent appointments until payment is resolved.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Convenient Payment Options&#8221; tab_id=&#8221;1760423330990-57d7b516-fb04&#8243;][vc_column_text]Balances over $10 may be charged to your Visa or MasterCard. To simplify billing, we encourage families to complete a\u00a0<strong>Credit Card Authorization Form<\/strong>. Please print, fill out the form, and return it by mail, fax, or in person at your next appointment.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Financial Hardship and Payment Plans&#8221; tab_id=&#8221;1760423330551-322968db-a896&#8243;][vc_column_text]If your family is experiencing financial hardship, let us know. We\u2019re happy to work with you to arrange a reasonable payment plan. Our priority is ensuring your child receives the care they need.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Returned Checks&#8221; tab_id=&#8221;1760423330239-1b268a7a-ce5c&#8221;][vc_column_text]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.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Payment at Time of Service&#8221; tab_id=&#8221;1760423329504-cc724c18-ff7b&#8221;][vc_column_text]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.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Unpaid Balances&#8221; tab_id=&#8221;1760423465999-a1245e01-ea01&#8243;][vc_column_text]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.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Forms and Letters&#8221; tab_id=&#8221;1760423465793-cb896f7e-0dbb&#8221;][vc_column_text]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\u2019d prefer them mailed, please include a self-addressed stamped envelope.[\/vc_column_text][\/vc_tta_section][\/vc_tta_accordion][\/vc_column][\/vc_row][\/vc_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_section full_width=&#8221;stretch_row&#8221; content_placement=&#8221;middle&#8221; css=&#8221;.vc_custom_1760423196549{margin-top: px !important;padding-top: 50px !important;padding-bottom: 50px !important;background-color: #ffffff !important;}&#8221; el_class=&#8221;color-white-li&#8221;][vc_row content_placement=&#8221;middle&#8221;][vc_column width=&#8221;1\/2&#8243;][vc_single_image image=&#8221;476&#8243; img_size=&#8221;full&#8221; el_class=&#8221;about-img&#8221;][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text] Forms &amp; Policies TLC Pediatrics of Amarillo, PA is an independent, self-owned and operated pediatric group. On this page, you\u2019ll find information about our general office policies as well as links to some of the forms [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-195","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-json\/wp\/v2\/pages\/195","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-json\/wp\/v2\/comments?post=195"}],"version-history":[{"count":29,"href":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-json\/wp\/v2\/pages\/195\/revisions"}],"predecessor-version":[{"id":836,"href":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-json\/wp\/v2\/pages\/195\/revisions\/836"}],"wp:attachment":[{"href":"https:\/\/cmscustom-staginglink2.com\/Tlc-Pediatrics\/wp\/wp-json\/wp\/v2\/media?parent=195"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}