It is the goal of the physicians and staff of SouthPark Pediatrics to accommodate as many request as possible to the furthest reasonable extent, bearing in mind the following limitations: • Blank forms will not be accepted. Forms will only be accepted for completion if the patient's name and other information has been completed. We will not be able to begin to complete or certify a form if parents have not completed their parts of the forms prior to form submission. • Many forms require the information to be based on an examination completed within 12 months of the date the form is completed. The Academy of Pediatrics recommends annual check ups after the initial well child care evaluations to 3 years old. SouthPark Pediatrics will not complete forms for patients who are not up to date with the scheduled check ups. We do not waive annual check ups or parts of the American Academy of Pediatrics recommendations including the Developmental Assessment due to lack of insurance coverage. • Physical examination requires checks of perceptual ability, ie, hearing and vision screening. We regret that we cannot certify a child fit for any program without appropriate perceptual (hearing and vision) testing. • Forms are completed on the basis of examinations conducted by physicians in this medical group. Examinations performed by "checkup centers" will not be cosigned by your physician, nor will he or she complete any forms based in whole or in part on any information provided by such centers. • Turnaround time for form completion is usually fewer than 10 business days. While every effort will be made to complete forms as quickly as possible, parents should realize that at certain times of the year we may receive hundreds of health forms in one week, and remember that patients with health concerns may need to be carefully reviewed by a physician before it is released. Parents are strongly advised not to wait until the last moment to look at the paperwork they have received from the program their child is scheduled to attend. (See below for rush service* information). • Forms will be held here for parents to pick up or will be sent to the patient's home in a self addressed stamped envelope. Because of Health Insurance Portability and Accountability Act (HIPAA) regulations, forms will be released to parents only. Federal law prohibits doctors' offices from faxing or mailing medical information to nonmedical facilities. We cannot be responsible for delays or losses in the mail. • Forms are completed for those whose accounts are in good standing. Delinquent accounts must be brought current before forms will be released. Forms must be paid for before they are released. We request that the individual requesting FMLA complete form details, understanding that the physician will review the information before signing. The front office staff does not have the authority to alter, reduce, or change charges. There is a $10.00 charge for completion of all FMLA forms. • Insurance companies do not reimburse for form completion, and we do not bill insurance for completing any form. The minimum charge for review or completion of a form is $15.00. This charge is waived if the form is "routine" (not extensive) and brought for completion at the check up. • Rush service may be available for an additional $10.00.If available, we will have your form completed in three business days. We do not guarantee the availability of this service.
SouthPark Pediatrics, PA Reserved patient and general visitor parking. 4601 Park Road, Suite 100, Charlotte, NC 28209 (704)522-6656 Email: info@southparkpediatrics.net