150 Hindman Rd, Butler, PA(724) 283-KIDS
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Patient Demographics

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Quick Care Pediatrics

150 Hindman Road, Butler, PA 16001
Phone 724-283-5437   Fax 724-285-5437

Patient Demographics

Patient Information
Household Contact Information
Insurance Information
Person Responsible for the Bill
Quick Care Pediatrics

150 Hindman Road, Butler, PA 16001
Phone 724-283-5437   Fax 724-285-5437

Consent for Information

I hereby consent to Quick Care Pediatrics discussing and providing information to the following individual(s).

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Quick Care Pediatrics

150 Hindman Road, Butler, PA 16001
Phone 724-283-5437   Fax 724-285-5437

Appointment Policy Agreement

Our goal is to provide quality health care to all of our patients in a timely manner. No-shows, late arrivals, and cancellations inconvenience not only our providers, but our other scheduled patients as well.

When you book your appointment, you are holding a space on our schedule that is no longer available to our other patients. If a cancellation is necessary or you need to reschedule, please call our office 48 hours prior to your child’s scheduled appointment time.

A no-show is when a patient misses an appointment without canceling. A late arrival is when a patient arrives fifteen minutes after their scheduled appointment time. A provider reserves the right to refuse to see a patient who arrives after the grace period. A cancellation is when the appointment is cancelled less than 48 hours prior to the appointment time.

THREE failures to keep your child’s scheduled appointment, whether they are no-shows, late arrivals, or late cancellations, may result in discharge from our practice.

I have read and understand this office policy and agree to comply.

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Quick Care Pediatrics

150 Hindman Road, Butler, PA 16001
Phone 724-283-5437   Fax 724-285-5437

Office Financial Policy

We would like to thank you for choosing Quick Care Pediatrics as your child’s provider. To keep you informed of our current financial policy, we ask that you read and sign our financial acknowledgment prior to any treatment. A copy of this agreement can be provided for future reference.

  • If required by your insurance (typically, but not limited to, Medicaid, CHIP, or an HMO), please make sure to list one of our medical doctors and our office address on the policy. Failure to do so before an appointment can result in the patient guarantor assuming financial responsibility for that date of service.
  • Please present all current insurance cards at the time of every visit. This verifies the correct insurance and provides consent to bill the plan on your child’s behalf. Failure to do so before an appointment can result in the patient guarantor assuming financial responsibility for that date of service.
  • It is your responsibility to understand your specific insurance policy. This includes, but is not limited to, preauthorization or prior authorization requirements, copay amount, deductible amount, and coinsurance amount.
    • Copays are due at the time of service. There will be an additional 10% processing fee added toward the copay amount if it is not paid at the time of the visit.
  • Not all services rendered by our office are covered by every insurance plan. Any office visit, testing, and/or laboratory services not covered by your insurance plan will be your financial responsibility.
  • If our providers are not in network or accepting your insurance plan, payment for rendered services is due at the time of the appointment.
  • Self-pay appointments are accepted, and payment is due at the time of the appointment.
  • Patient balances are billed immediately upon receipt of your insurance plan’s explanation of benefits. Your remittance is due upon receipt of your bill.
    • Balances that enter delinquent status may result in your account being sent to collections and your child being discharged from the practice. Prompt payment is appreciated.

I have read and understand this office policy and agree to comply with the responsibility for any payment that becomes due as outlined above.

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Quick Care Pediatrics

150 Hindman Road, Butler, PA 16001
Phone 724-283-5437   Fax 724-285-5437

HIPAA Privacy Rule

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by law to:

  • Maintain the privacy of Protected Health Information (PHI).
  • Give you this notice of our legal duties and privacy practices regarding health information about you.
  • Follow the terms of our notice that is currently in effect.

The following describes the ways we may use and disclose health information that identifies you. Except for the purposes described below, we will use and disclose your PHI only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.

We may disclose your PHI to doctors, nurses, and other health care personnel who participate in your health care. Your PHI may be shared with outside entities performing ancillary services. We may use and disclose your PHI for health care operation purposes. We may also send or communicate appointment reminders that are subject to our normal confidentiality policies and any special instructions you have requested.

For uses beyond treatment and operations purposes, we will ordinarily seek to obtain your authorization before disclosing your PHI. However, disclosure of your PHI may be made without your consent or authorization when required by law, when required for public health reasons, when necessary to avert a threat of harm to you or a third person, or when other circumstances may require or warrant such disclosure.

We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

We are required by law to disclose PHI in response to any court or administrative order.

We are required by law to release PHI if asked by a law enforcement official.

We may release PHI to a coroner or medical examiner.

You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request in writing to our practice Privacy Officer. We have up to 15 days to make your Protected Health Information available to you, and we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. If we deny your request, you have the right to have the denial reviewed by a licensed health care professional who was not directly involved in the denial, and we will comply with the outcome of the review.

You have the right to request that an electronic copy of your record be sent to you or transmitted to another individual or entity. If the PHI is not readily producible in the form or format you request, your record will be provided in our standard format.

You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

You have the right to request a list of certain disclosures we made regarding Health Information for purposes other than treatment, payment, and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request in writing to our office Privacy Officer.

You may receive a paper or electronic copy of this notice upon request.

We reserve the right to change this notice at any time.

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. If you have any questions or concerns about our privacy practices, please contact our office.

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Quick Care Pediatrics

150 Hindman Road, Butler, PA 16001
Phone 724-283-5437   Fax 724-285-5437

HIPAA Authorization to Release Protected Medical Records

This request expires 90 days after the date entered below.

I hereby authorize the following person or facility to release only the medical records selected below to Quick Care Pediatrics for continued care.

Records to Release

I understand that the information used or disclosed may be subject to re-disclosure by the person, persons, class, or facility receiving it and would no longer be protected by federal privacy regulations.

I may revoke this authorization by notifying the facility in writing of my desire to revoke it. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

I understand that the provider to whom this authorization is furnished may not condition its treatment of me on whether I sign this authorization.

HIV-related information obtained in the parts of the records indicated above will be released through this authorization unless otherwise indicated.

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