Office Forms & Downloads
New Patient Forms
- Please download and complete these forms prior to your first appointment.
- New Patient Registration Packet
- Records ReleaseUse this form to transfer records to Millburn Pediatrics from another practice.
Well Child Visit Handouts
- These handouts from the AAP provide valuable information and suggestions for parents and patients, based on your child’s age.
- Bright Futures Handouts for ParentsBirth to 17 Years
- Bright Futures Handouts for Patients7 to 21 Years
Billing & Insurance
We are committed to providing the best possible care and service to you, and appreciate your understanding of your financial responsibilities as an essential part of your child’s care. If you have any questions concerning these policies, please contact our office.
It is Your Responsibility
- To know the limits and coverage of your particular health insurance policy.
- To show your child’s current insurance card(s) to us at each visit.
- To pay any copay and/or outstanding balance at the time of your visit.
- To keep us up-to-date with your most current insurance information. If the insurance information is incorrect, you will be responsible for the charges and payment of the visit.
- To designate Millburn Pediatrics as your PCP, if required, and to make sure this appears on your insurance card prior to any visits. If your insurance company has not been informed that our practice is your PCP, you may be financially responsible for your current visit.
Our billing staff will do their best to assist you with insurance questions; however, if you have questions about your coverage, it is best to check with your specific insurance company.
Accepted Insurance
- To be as accessible as possible to the families in our community, we accept most insurances. Please contact your insurance carrier to verify that Millburn Pediatrics is in their network.
- Aetna
- AmeriHealth
- Cigna
- Emblem Health/GHI/HIP
- Horizon BCBS
- Magna Care
- Meritain
- Multi Plan
- Nippon Life
- Oscar
- PHCS
- Tricare
Payment Methods
We accept cash, checks and major credit cards. A $25 fee will be charged for any checks returned due to insufficient funds.
Credit Card on File (Auto-Pay)
By automatically processing payments and co-pays, Auto-Pay makes your visits faster and your payments much easier, saving your time and mail and paperwork. Beginning January 1, 2025, families will be required to leave a credit card on file. Learn more about Auto-Pay.
Self-Pay
Self-pay patients are expected to pay for services in full at the time of the visit.
Lab Testing
Your insurance may not pay for in-office testing, such as (but not limited to) hemoglobin, lead, strep, covid, mono, urine dips, molecular tests, covid antigen test, blood sugar, and stool occult blood testing. They may prefer that you go to a contracted lab, such as Labcorp or Quest. If you choose to have these tests done in the office and your insurance does not cover the testing, you will be responsible for the cost.
Appointment & Office Policies
We make every effort to meet the needs of our patients by offering preventative well child visits, as well as same-day sick visits when at all possible. Please contact the office to schedule a visit. Appointments are required.
Mutual Respect of Time
Our providers strive to stay on schedule, and we value the time we have set aside to see and treat your child. Although there can be emergency situations that prevent us from running on time, we pledge to provide quality care with minimal wait time to the best of our ability.
- If you are unable to keep a well visit appointment, we require 24 hours notice. There is a $50 fee for missed appointments on weekdays, and $75 on weekends.
- If you are late for your visit by 15 minutes or more, we will do our best to accommodate you. However, it may be necessary to reschedule your appointment.
- We strive to minimize any wait time; however, emergencies do occur and will take priority over a scheduled visit. We do appreciate your understanding.
Prescription Refills
We require one week’s notice for any medication refills. It is your responsibility to make ADHD medication check-ups every three months, we will NOT refill children’s prescription without an appropriate appointment.
Referrals
- It is your responsibility to know if a referral is required to see a specialist, whether a pre-authorization is required before a procedure, and what services are covered.
- Advance notice is needed for non-emergent referrals, typically 3 to 5 business days. Please make this request through the portal and advise the requirements needed to complete the referral.
- It is your responsibility to know if the selected specialist is in your plan.
Forms
- If you request forms to be filled out, there is an annual $20 form fee per child. This is a one-time per calendar year charge. This fee must be paid prior to completing the form. No exceptions.
- Please upload your form request to the portal. Make sure your child’s name is on all pages and your portion of the form is completed. We cannot clear a child to participate in sports without reviewing the History Page filled out by the family.
- Please plan ahead. We ask for 7-10 days to complete all forms.
- The patient must have had a well visit within the last 12 months.
We are a vaccinating practice.
The physicians at Millburn Pediatrics adhere to the American Academy of Pediatrics guidelines on immunizations. Our goal is to complete your child(ren)’s primary vaccine series by the time they are 2 years of age, then work to ensure that all subsequent vaccines are given on time.
If you choose not to vaccinate your children, we are not the pediatrics practice for you.
Resources
- Immunization ScheduleAmerican Academy of Pediatrics (AAP)
- Vaccine Information StatementsCenters for Disease Control and Prevention (CDC)
- Vaccine Safety: The FactsAmerican Academy of Pediatrics
- VaccinateYourFamily.orgHelping to protect people of all ages from vaccine-preventable diseases
- Institute for Vaccine SafetyJohns Hopkins Bloomberg School of Public Health
- Centers for Disease Control (CDC)
- Immunize.orgFormerly Immunization Action Coalition (IAC)
- Vaccine Education CenterChildren's Hospital of Philadelphia