Patient Forms

To expedite your first appointment, please arrive a few minutes early to complete registration forms so that we have all the necessary information to treat your child. You may also download and print the forms from this website, fill them out ahead of time, and bring them with you to the first appointment.

New Patient Packet
General Consent Form
Child Patient Demographic Form
Adult (18+) Patient Demographic Form
Family History Form
Release of Records Authorizations
Notice of Privacy Practices
Billing Policy
   
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Billing & Insurance

We strive to serve our patients efficiently and effectively.  In order to do so, we request that each patient do their part to help us by following the policies outlined below regarding insurance and payment.

It is the patient’s responsibility to:

        Know your insurance plan.  Bring your insurance card to each visit. 

        Know what’s covered by your insurance plan.  Not all insurance contracts are the same.  It is your responsibility to be aware of your insurance company’s provision of payment for all visits.  This includes all office visits, well-child exams, sports physicals, labs and immunizations. 

        You are responsible to make co-pays at the time of your visit.  All other patient responsibilities for deductible, coinsurance and non-covered services are expected no later than 30 days from the receipt of your statement.  If you need to make alternate payment arrangements, please call our billing department promptly at 952-943-0027.  Unpaid balances may be subject to collections.

        If your insurance requires a primary care plan, please choose “All About Children Pediatrics” as your primary care physician.

        Please advise the front desk staff of any changes to insurance coverage, home address, and telephone numbers at the time of check in.

        Notify your insurance company and/or your employer’s Human Resources Department about the birth of any new baby within 30 days of their birth.     

        All About Children Pediatrics expects the parents to work out payment arrangements with each other.  We will not get involved in any disputes that arise between the parents regarding responsibility for payments. 

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