Download Office Policies:
Notice Of Privacy Practices
For refill requests of routine or maintenance medications, please call the office during regular office hours and allow for three business days for the doctor to review your child’s health record and complete the request.
To avoid misdiagnosis and ensure your child’s safety, it is our policy not to provide antibiotic prescriptions to patients who have not recently been seen.
Cinco West Pediatrics asks that you submit requests for referrals at least five business days prior to your scheduled appointment with your child’s specialist. Please provide: The child’s full name, date of birth, parent or guardian’s name, contact phone number, name of insurance, date of appointment, specialist’s complete name, office phone number, and diagnosis or reason for the office visit. Once the referral has been completed, the parent or guardian will be notified by phone that it is ready to be picked up at our office. Referrals will not be faxed.
It is the responsibility of the parent or guardian to submit a referral request in a timely manner. Only under extreme emergency circumstances will same-day referrals be approved and provided. Referrals cannot be back-dated, and in most cases, your insurance will require 24-to-48-hour notice to authorize the referral.
School, Camp and Sports Physicals:
If you have a form that needs to be completed for team sports, camp, or other activities, and you have had a routine well-child examination within the past 12 months, please bring the form to our office for us to complete. Please do not fax us your form. You may pick up the completed form after five business days. There is currently no charge for this service. Please note: We cannot fill out the “physician” portion of any form until the “parent” portion has been completed.
For patients who fail to come to their scheduled appointment and do not notify our office at least 24 hours in advance of the need to cancel the appointment, a $25.00 no-show fee will be charged to their account. This charge will be the patient’s responsibility; insurance companies will not pay for this. Please notify our office if you cannot keep your appointment so that other patients in need of medical care can be seen.
You have a responsibility to arrive at our office at your scheduled appointment time. Cinco West Pediatrics reserves the right to reschedule appointments for patients who arrive more than 20 minutes late for their appointments.
Authorization for Medical Care:
If the adult accompanying your child to our office is not already listed on his/her Authorization for Medical Care form, please fill out the following form and fax it to our office or send it with your child at the time of the appointment.
Release of Medical Records:
If you know your new doctor’s office location, you can fill out the following form so we can fax your child’s medical records. If you are unsure of where you will be going, we suggest you wait until you go to the new doctor’s office and complete a Release of Medical Records form at his/her office. When the release form is forwarded to us, we can send your records.