New Patient Forms

The following documents should be filled and must be presented before your first visit.

Please bring the following to your first visit:

  • Your Child’s Immunization Records
  • Insurance Card
  • Caregiver’s Driver License


Prescription

ADHD/Mental Health Initial Evaluation


If you have concerns that your child might be autistic, please also visit http://www.childbrain.com/pddassess.html. Fill out the ASD Assessment Scale/ Screening Questionnaire, score it, print it out (2 pages) and bring it to your initial visit.

ADHD/Mental Health Follow Up

Premier Pediatrics Policy for ADHD management

Premier Pediatrics Discounted/Sliding Fee Policy

Policy

It is the policy of Premier Pediatrics to provide essential medical services to all patients, regardless of the patient’s ability to pay. Discounts are offered to those who qualify based upon family/household size and annual income. A sliding fee schedule is used to calculate the basic discount and is updated each year using the Federal Poverty Guidelines. Once the application is approved, the discount will be honored for six months, after which the patient must reapply.

Discount Application Process

To apply for our Sliding Fee Schedule, the patient must provide necessary documentation along with a completed application. The required documentation includes proof of:

  • Home Address
  • Household Income
  • Insurance Coverage

If the applicant appears to be eligible for Medicaid, a written denial of coverage by Medicaid may also be required.

The discount will apply to all services received at this clinic, but not those services purchased from outside, including reference laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services. This form must be completed every 6 months, or if your financial situation changes.

NOTE: To comply with federal regulations, in order to give you a discount on our medical services, it is necessary for us to ask some personal questions. Your answers will be kept on file and in strict confidence.

Your yearly income tax return, a copy of your W-2 form, last month’s paycheck stubs, copies of your social security checks, or other checks you may receive will be sufficient proof. Your annual income and your family size will be used to calculate your discount.

Download Discounted/Sliding Fee Application (pdf)

Request an Appointment Moms-to-be: You’re invited to a special get to know your “Baby’s First Doctor” introductory appointment.
CLICK HERE for more information or to request an appointment.

Schedule an appointment with Premier Pediatrics. We have time for your kids.