Parent Resources and Office Policies

Parenting Help

Our Health Library information does not replace the advice of a doctor. Please be advised that this information is made available to assist our patients to learn more about their health. Our providers may not see and/or treat all topics found herein.

As parents, especially if this is your first child, you always have questions and concerns. Our For Parents section is here to try and help address some of the more common issues we are often asked as pediatricians.

Pediatric Health Library
Search our comprehensive online library of health topics related to children.

Offered through HealthyChildren.org. Is Your Child Ill? Whether you’re on the go or at home, this app will help you know what to do next.

Is Your Child ILL?
Use our Symptom Checker.

Online Resources

Download Patient Forms

To view the forms listed below, you will need Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.

For your convenience, we have posted the forms that New Patients will be asked to complete when you visit one of our offices. These forms are available in PDF format and are available for you to download, print, and complete before coming to the office. By completing forms ahead of time, you can minimize the amount of time you spend at our office

New Patient Forms

All patients under the age of 18 and new to the practice MUST be accompanied by a parent or legal guardian for their first visit.

Additional Forms

NOTE: Please do not fill out the Vanderbilt Teacher/Parent Follow-Up forms if your child has not been in for an Initial ADD/ADHD appointment.  You NEED to call the office and we will send you Initial Vanderbilt Forms to fill out.

Please fill out ALL the highlighted information on the OHSAA sports form before submitting.

Your Rights and Protections Against Surprise Medical Bills

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

The law, which became effective on January 12, 2022, protects patients from receiving and paying surprise medical bills above the patient’s in-network rate from health care providers for emergency care or, in certain circumstances, unanticipated out-of-network care. Cost sharing amounts, which include coinsurance, copayments, and deductibles, are limited to the patient’s in-network amounts.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact https://www.cms.gov/nosurprises/consumers

Visit https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf for more information about your rights under federal law.

Visit https://insurance.ohio.gov/strategic-initiatives/surprise-billing/resources/01-surprise-billing for more information about your rights under Ohio laws.