Policies & Forms
Learn about the policies that help us provide your children with the very best of care.
Office Forms & Downloads
New patient forms, office policies, screenings, and more.
New Patient Forms
- Please download and complete these forms prior to your first appointment.
- Patient Registration
- Authorization to Transfer Records to HRP
- Disclosure Authorization
- HIPAA Privacy Authorization (18+ Years)
- Financial Policy
- Easy Pay Agreement
- Preventative Visits
Office Documents & Policies
Well Child Visit Handouts
- Bright Futures Parent HandoutsBirth to 17 Years
- Bright Futures Patient Handouts7 to 21 Years
Screenings
- Covid Vaccine Screening
- CRAFFT QuestionnaireScreen for substance-related risks and problems in adolescents
- Edinburgh Postnatal Depression Scale (EPDS)En Español
- GAD-7 Anxiety
- Lead Assessment
- Parents’ Evaluation of Developmental Status (PEDS)En Español
- Patient Health Questionnaire (PHQ-9) Depression Screening
- Pediatric Symptom Checklist (PSC-17)
- Tuberculosis Screening
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 pay any deductibles and/or outstanding balance within 30 days.
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
- Our office accepts most–but not all–plans with these insurance companies. It is your responsibility to check with your insurance carrier to confirm that your plan is in network with our office.
- AetnaWe do not accept Aetna Whole Health.
- Blue Cross Blue ShieldWe do not accept any EPO plans.
- Cigna
- Connecticare
- HUSKY Health/Medicaid
- Multiplan
- Oxford
- PHCS
- United Healthcare
Payment Methods
We accept cash, check, credit cards, and Health Savings Account (HSA) cards for payment.
Credit Card on File (Easy Pay)
As a convenience to our patients and to simplify the billing process, we require that a valid credit card/HSA card be kept on file. The card information is stored electronically in an encrypted form and cannot be viewed by our office staff. Your signature will authorize the card to be used only when your balance becomes past due. Learn more by reading our Easy Pay Agreement.
SELF-PAY/UNINSURED
If you have no insurance, we require a $125.00 deposit (sick visits) and $175.00 (well visits), prior to your child(ren) being seen. We offer a 20% discount if the visit is paid in full on the day of the service. The discount will be applied at check-out and the deposit will be applied to your balance. Any remaining balance must be paid after the visit at check-out. Discounts are not applied to vaccines.
Appointments & Office Visits
We make every effort to meet the needs of our patients by offering preventative well child visits, as well as same-day urgent care appointments when at all possible. Please contact the office to schedule a visit. Appointments are required.
Reminders
It is your responsibility to remember your scheduled appointment day and time. As a courtesy, we offer appointment reminders. However, there may be situations in which you may not receive a text, email, or call due to unforeseen circumstances. In this case you are still expected to maintain your appointment, otherwise a fee will be applied to your account. It is your responsibility to update/notify the staff as to your preferred method of communication.
Cancellations
For appointments canceled with less than 24 hours notice a $50.00 fee will apply. If you are more than 15 minutes late to your appointment, we consider this a missed appointment and the fee will also apply. This fee must be paid in full before your appointment will be rescheduled. If you have 3 missed appointments it may result in dismissal from the practice.
SICK COMPLAINTS DURING WELL VISITS
Insurance companies require us to file all services offered at a visit. Well child care and sick child care are separate codes for the insurance. We may complete visits at the same time for your convenience if time allows, but at times this may result in co-pays and deductibles just as it would if it were billed on a separate day.
Letters & Forms
There is a charge for all forms not requested at a regular well child visit. The charges are as follows:
- HEALTH FORMS: $10.00
- SAME DAY HEALTH FORM: $15.00 (If we are able to accommodate)
- FMLA/Physician Letters: $50.00 (May require a separate office visit)
ONE school/sports form will be provided per year, given at the well child visit, at no charge. The school/sports/camp/daycare form will be saved to your child’s chart and you will have access to it via our patient portal. We will not send or fax these to the school, nor will we send immunization records. All are available in the patient portal. You can forward them to the school at your convenience.
After-Hours Care
For true emergencies please call 911 or go immediately to the hospital.
Night Nurse Triage
For urgent matters that cannot wait until business hours, our office provides an after-hours emergency triage service (4:30pm–8:00am) for cases where a parent or caregiver needs to speak with a registered nurse for medical advice.
- There is a charge of $25.00 for this service that is not covered by insurance. This will be billed directly to you.
- Many health insurance companies have their own nurse advice line. Please check the back of your insurance card/policy for details.
- For all other routine calls such as medication refills, dosing questions, etc. please call during our regularly scheduled hours.
Other Resources
- Please see our medication dosage calculator and this symptom checker from the AAP. Both these tools provide valuable information.
- Many health insurance companies have their own nurse advice line. Please check the back of your insurance card/policy for details.
- You may send a message through our patient portal that will be dealt with during the next business day.
Urgent Care
While we would prefer to keep your child’s non-emergency sick visits in office, we understand that this is not always possible.
PM Pediatric Care
1500C Pleasant Valley Rd
Manchester, CT 06040
860-926-2767
PM Pediatric Care
1459A New Britain Ave
Corbin’s Corner Shopping Center
West Hartford, CT 06110
860-232-5437
Connecticut Children’s Urgent Care
599 Farmington Ave, Suite 202
Farmington, CT 06032
860-837-5170
Hospitals
We are affiliated with Connecticut Children’s Physician Network, which helps us coordinate care for your child in order to provide the highest-quality care.
Poison Control
For ingestions, please contact Poison Control at (800) 222-1222 and follow their instructions. There is no fee for their services.
Suicide & Crisis Lifeline
Vaccines save lives.
At Healthy Roots Pediatrics, we strive to provide comprehensive, family-centered care for all of our patients. We aim to maintain a safe environment where our families receive exceptional medical care compliant with both the American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC).
We firmly believe that vaccinating our patients is one of the most important services we offer. Vaccines prevent serious illness and save lives. We recommend that children and young adults receive vaccines according to the schedule published by the AAP and CDC. The published schedule is the result of years of scientific study and accumulation of data on millions of children.
As of January 1, 2021, Healthy Roots Pediatrics will no longer accept families who choose not to vaccinate their children. If your decision is to decline immunizations, we will ask you to find another healthcare provider who shares your views.
In some cases, we may consider altering the schedule to accommodate parental reservations while still keeping the child up-to-date. If a parent elects to deviate from the vaccine schedule, the child must return to the office at 1-2 week intervals to stay within the recommended “window” for the vaccines. All parents who do not follow the AAP and CDC schedule must sign a waiver that they are utilizing an alternate vaccine schedule. Additional visits for these vaccines may result in co-pays depending on your insurance coverage.
As medical professionals, we feel very strongly that vaccinating children on schedule is the best choice for your children.
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