Forms & Office Policies

For your convenience, all of our office forms are now available online, so you can download and complete them before your next office visit. We highly recommend completing the forms prior to your appointment to shorten wait times for you and your child.

We have also included all of our office policies pertaining to scheduling and canceling appointments, payment methods, insurance, prescription refills, and more.


New Patient Registration Packet

If you are a new patient and have not completed our New Patient Registration Packet, please open it in the link below and complete it prior to your child's first appointment.

If you have completed our New Patient Registration Packet in the past, but need to make revisions to one or more forms in the packet, you can download the individual forms you need from the section below.

New Patient Registration Packet
Nuevo Paquete de Registro de Pacientes



Other Forms & Office Handouts

If you need your child's medical records released to our office from a previous physician, or if you need us to send our records to a new physician, please print out and complete the Release of Infomation form below and our staff will initiate the transfer process.

Release of Information


Appointment Policies

It is our policy to accommodate as many appointment requests as possible, while still providing our patients with the prompt, professional care. With this in mind, we ask that you review our appointment policies, as they can directly affect the quality of your office experience.

Scheduled Appointments

We ask that, if possible, you arrive early to your scheduled appointments. Administrative requirements pertaining to registration, check-in, or insurance can sometimes take several minutes. Arriving early ensures that these requirements are met, without limiting the time spent with your doctor.

Same-Day Sick Appointments

We are no longer accepting walk-in appointments and ask that you always schedule a time for your same-day visit. We do reserve several same-day appointments, and making an appointment lessens the time spent in the waiting room with a sick child.

New Patient Appointments

If you are a new patient who has scheduled your first appointment, we ask that you open, print out, and complete our New Patient Registration Packet prior to your visit. This will help shorten your wait time and increase the time spent with your pediatrician.

Running Late?

If you know you are going to be late, or unable to make your scheduled appointment time, please call ahead and we will do all we can to accommodate you and minimize the need to reschedule your child's appointment.

Cancellation Policy

If you need to cancel or reschedule an appointment, please do so prior to the appointment date, by calling our office during regular business hours.

Missed Appointments

Missed appointments for routine/preventive care are very disruptive to our office and deprive other patients of the opportunity to see the doctor. All missed appointments will incur a $25.00 no-show fee.



Financial Policies

The following information is a summary of our financial policy. Please be sure you read and agree to these terms, as we require that you sign our payment policy form before your child receives treatment.

Full payment is due when services are rendered.

We ask that all co-payments, coinsurance, and deductibles be paid at the time of service, unless other arrangements have been made with our office manager prior to your appointment. This helps us keep our costs down.

If you are covered by an insurance plan that we participate in, we will bill your insurance company and only require you to pay the authorized amount (co-pay, coinsurance, or deductible) at the time of service. Please remember that each child seen by the doctor will have a separate co-payment. For any services provided at Northeast Georgia Medical Center, we will also bill your health plan.

For all services rendered to minor patients, the parent or guardian with custody who accompanied the patient will be responsible for payment.

Non-covered Services

Please be aware, some services may not be covered by your insurance plan and will not be reimbursed. In this case, you are personally responsible for the charges and will be mailed a statement from our office indicating the remaining balance. Payment is due upon receipt of the statement from our office.

If you are uninsured, unable to provide proof of insurance, or on an insurance plan that we do not participate in, full payment will be required at the time of your visit.

Payment Methods

We accept payment by cash, check, Visa, Mastercard, Discover, and American Express.

Insurance and Health Plans

We proudly participate in many different insurance plans. Please remember to bring your driver's license and insurance card with you to your child's appointment.

Below is a list of insurance plans that we currently participate in:

Aetna
Affordable/Health Care Compare
America’s Health Plan
Amerigroup
BCE Emergis
Blue Cross/Blue Shield of GA
Cigna
Community Care Networks
Coventry
First Health
Focus Healthcare Management
Galaxy Health Network
Medicaid
MultiPlan

National Hospital Network
Northeast GA Health Partners Plus
Peachcare for Kids
PeachState Health Plan
Preferred Health Network
Preferred Plan of GA
Principal Healthcare (PHCS)
Southcare – PPO
Tricare
United Healthcare
United Payors
United Providers
USA Managed Care
WellCare

** Please note: This list is frequently updated, please ask if your plan is not listed. **



Privacy Policy

The Department of Health and Human Services has established a "Privacy Rule" to help govern the use and disclosure of Protected Health Information (PHI). Your PHI includes individually identifiable health information related to your past, present, or future health care services. This rule was also created to provide a standard for health care providers to obtain their patients' consent for uses and disclosures of health information, in order to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal medical records, and will always take reasonable precautions to secure and protect that privacy. When it is appropriate and necessary, we provide the minimum required information to those in need of your PHI, in order to provide health care that is in your best interest.

We also want you to know, we support your full access to your personal medical records.

We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you, should you choose to refuse to disclose your PHI. If you choose to give consent, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this, or a previously signed, consent.

To Our Current Patients

The misuse of Protected Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and costing money. We want you to know that all of our employees, managers, and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA), with particular emphasis on the “Privacy Rule.” We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws, and regulations. We want to ensure that our practice never contributes, in any way, to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program to help us prevent any inappropriate use of PHI.

We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients, without any thought of penalization, if they feel that an event compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly.

Thank you for being one of our highly valued patients!



Prescription Refill Policy

We do not refill regular medications after hours, or on weekends.

Routine Prescription Refills

For routine prescription refills, please call our office by 4:00 pm, between Monday and Friday. Your prescription will typically be called in to your pharmacy by 6:00 pm that day. Any calls regarding routine prescription refills, that are made after 4:00 pm, will be called in to your pharmacy the next business day.

ADD/ADHD Medications

We require 24-hours advance notice from patients who are in need of ADD or ADHD medication refills. These prescriptions must be picked up at our office, during regular business hours.

We have phone coverage 24 hours a day, 7 days a week. During our lunch break (12:00pm - 1:15pm) and after hours, you will be connected to our answering service. For urgent concerns, you may page the doctor directly through the answering service. For life-threatening emergencies, please call 911.

If you have questions, concerns, or would like to make an appointment, call the number below to reach our office.

(770) 287-1788

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Mountain View Pediatrics
2049 Beverly Rd.
Gainesville, GA 30501

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Mountain View Pediatrics
2049 Beverly Rd.
Gainesville, GA 30501

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Office Hours

Monday 8:00 a.m. - 4:30 p.m.
Tuesday 8:00 a.m. - 4:30 p.m.
Wednesday 8:00 a.m. - 4:30 p.m.
Thursday 8:00 a.m. - 4:30 p.m.
Friday 8:00 a.m. - 4:30 p.m.
Saturday 9:00 a.m. - 12:00 p.m.
Sunday Closed
Same-day appointments available.

We have phone coverage 24 hours a day, 7 days a week. During our lunch break (12:00pm - 1:15pm) and after hours, you will be connected to our answering service. For urgent concerns, you may page the doctor directly through the answering service. For life-threatening emergencies, please call 911.

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