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Patient Service Plan 2023 - Heights Pediatrics
This form is required for all families.
You must either
Accept
or
Decline
the plan.
Only one Google Form per family
For more info on the Patient Service Plan, please review our
newsletter
.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
OPTIONS
Annual Patient Service Plan:
$100 per child for July-Dec of 2023
$200 per child for Jan-Dec of 2024
OR
Individual Services:
Forms/letters (aside from complimentary DOE & 504 forms requested during well visits; up to 10 business days turnaround time): $50 each
Expedited form fee (same day service):
$50 add-on (
$30 if opted for PSP)
Refill requests
(same day or after hours):
$50 each
Miscellaneous non-medical services
(e.g. third-party conversations: schools, counselors, etc.):
$50 each
Prior authorizations: $75 each
Heights Pediatrics educational Zoom classes: $30 each
Infant and toddler CPR Class:
$100 per person (or $70 per person if opted for PSP)
New Mom’s Group:
$250 per person (or $200 if opted for PSP)
We reserve the right to implement price changes in the future.
I have read and understood the above policy. I elect to:
*
ACCEPT (Pay annual fee per patient)
DECLINE (Pay individually per non-covered service)
DECLINE (Have Fidelis Child Health Plus or Medicaid insurance)
Signed by:
*
Please list your full name. This serves as an electronic signature.
Your answer
Signer's Relationship to the Patient(s)
*
I am the Parent/Guardian
I am the Patient (must be 18+)
Signer's Cell Phone
*
Your answer
Today's Date
*
Your answer
Patient #1 Full Name
*
Your answer
Patient #2 Full Name
Leave blank if this does not apply
Your answer
Patient #3 Full Name
Leave blank if this does not apply
Your answer
Patient #4 Full Name
If there 4 or more patients, list all other names here. Otherwise, leave blank.
Your answer
Total Fees Due for 2023
*
If you accepted the Patient Service Plan 2023, select your total amount due. Please submit payment on the next page.
Otherwise, select an appropriate answer.
1 patient = $100
2 patients = $200
3 patients = $300
4 patients = $400
I declined the Patient Service Plan 2023 at this time and will be responsible for individual service fees as applicable
My child/children are on Fidelis (Child Health Plus Plan) or Medicaid
A copy of your responses will be emailed to the address you provided.
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