Billing Forms Insurance

PAYMENT & INSURANCE

Pediatric Partners of Virginia will directly bill your claims to most insurance companies.

• To better serve you and ensure proper billing we ask that you bring your insurance card with you to each and every visit.
• Be prepared to pay your copay.
• Be familiar with your insurance policy and any deductibles. If you have any questions please contact your insurance directly at the number listed on the back of your id card.
• If there is a balance owing on your account, we will send a monthly billing statement detailing the outstanding balance. You are encouraged to review the information carefully and
  compare it with your explanation of benefits (EOB) from your insurance company. If you have any questions regarding the balance that your insurance is requiring you to pay, please contact
  your insurance company directly.
• All balances are due within 30 days from the date on your statement. If you need to make other payment arrangements, please contact us.
• Pediatric Partners of Virginia reserves the right to request payment for outstanding balances. If the account is not paid in full or satisfactory arrangements made within a reasonable
  timeframe, we reserve the right to refer the account to an attorney and/or a collection agency for collection of balance. If collection is necessary, the responsible party or guarantor
  will be required to pay attorney, collection agency, and/or court costs up to 40% of the amount owing.

We do offer several payment plan options to assist you with paying off your balance. Payment arrangements are available by contacting our Billing Office by phone or email.

QUESTIONS? PLEASE CONTACT US

REMIT PAYMENTS TO:

9020 Stony Point Parkway Suite 165
Richmond, VA 23235
804.323.9100

PATIENT FORMS

Before meeting with you for the first time, it’s important that we know each other a bit. New Patient Forms will tell us about your
medical history, how we protect your privacy, and more. Below are some of the most commonly asked for forms our practices use on a regular basis.

New Patient Forms

Please read and complete the forms below before your first visit.

• Child and Family Patient Registration Packet
• Young Adult Registration Packet 18+
• Patient Rights and Responsibilities (HIPAA)
• Financial Agreement and Policy
• Medical Records Request
• Request to Limit and Restrict Access
• Request for Correction or Amendment
• No Surprises Act Notice
• Self-Pay and Eligibility Waiver

Attention Deficit Hyperactivity Disorder, Depression or Anxiety Forms

Please download and complete these parent and teacher rating scales prior to your appointment.

• Parent Vanderbilt Assessment
• Teacher Vanderbilt Assessment

Miscellaneous Forms and Additional Resources

• Virginia Department of Health Back To School Checklist
• Virginia HS Sports Physical Form
• Chesterfield Public Schools Health Forms
• Hanover Public Schools Health Forms
• Richmond Public Schools Health Forms
• Henrico Public Schools Health Forms
• Virginia School Entrance Health & Other Forms
• Pediatric Advisor 2022
• HealthyChildren.org
• Symptom Checker – HealthyChildren.org

SUBMIT YOUR COMPLETED FORMS HERE

ACCEPTED INSURANCE

Most of our physicians participate with the plans and payers listed below. If you have any questions regarding your plan participation or if your doctor is accepted on your
plan, please contact your insurance company.

• Aetna
• Aetna Better Health
• Anthem – All Products including Health Keepers Plus
• Champ VA
• Cigna
• Coventry Health Care
• First Health Network
• MAMSI
• Medicaid (most plans)
• MultiPlan
• Optima Health
• Preferred Care of Richmond–PCR
• Private Healthcare Systems–PHCS
• Southern Health Insurance/CareNet
• Tricare–Standard and Prime
• United Healthcare
• Virginia Health Network
• Virginia Premier

We do not participate with:

• Magellan Complete Care of VA

*Insurance participation may vary by location and physician. Please verify participation and coverage prior to each visit.