Download Forms

We have provided the following forms for our patients.  You can quickly and conveniently download these office forms.  Please bring your completed forms into the office at the time of your visit.

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Insurance Information

Heart of Texas Pediatrics participates in the following insurance plans:

Accountable Health Plan

Aetna

Affiliated Healthcare

BCBS Blue Choice

BCBS Par Plan

Beech Street

Blue Bell Creameries

Brazos Valley Network

ChoiceCare Network (HMO)

Cigna-BVN

Definity Health

First Care/Southwest Health & Life

First Health

Galaxy Health Network

Great West Healthcare

Healthsmart

Humana PPO

Humana/Military

MCD/TAX ID

MCD/Healthsteps/TAXID

MCR DME

MedCorp Southwest

Multispan/BCE Emergis/Admar

PHCS

PPO Next

Principal Life Ins

Pronet/Aetna/TRS (Teacher Retirement System)

Providence Health Alliance

Scott & White

Superior Health CHIP

Texas Municipal League

Texas True Choice

Tricare

Unicare

United American

United Healthcare

USA MCO PPO

Wells Cargo/Caresource

If your insurance is not on the list, please call your insurance company to see if we are a provider. We accept most insurances. Always make sure your policy covers preventive care, including well-child visits and vaccines. You are responsible for any services not covered by your insurance company.

WELL AND SICK VISITS AT THE SAME TIME

Your insurance company may cover well and sick visits differently, and it is very important that you familiarize yourself with the details of your insurance coverage.  No one likes being surprised with a bill! While some insurance may pay for well visits 100% (where there is no cost to you), sick benefits may include a co-pay, co-insurance, and/or a deductible.  If during a well visit your child is sick or has an issue that is not related to the normal growth and development of your child, and he/she needs treatment and/or medical attention for your concerns, your provider may bill the insurance company for both services. Regardless of whether there is a no charge for the well visit, you will be responsible for any charges passed on to you for any treatments and/or care given not covered.

Prescription Refills

For refills, please first contact your pharmacy first. If no refills are available, the pharmacy will send a request to our office. Refills on antibiotics generally will not be approved. An appointment will need to be scheduled. For refills on controlled substances such as ADHD medications, please contact us 24 hours in advance. We may require a recent office visit for refills on medicines for chronic conditions such as asthma and seizures.

 No Show Policy

A “no show” appointment is a missed appointment that was not cancelled prior to 12 hours before a well check/physical or 2 hours before a sick visit. In this event, a $50 fee/child will be charged.  Payment will be expected prior to rescheduling any appointment and is not reimbursable by your insurance.

Late Policy

In an effort to serve our patients in a timely manner, we request that you be on time for your scheduled appointment. If you are running late, please be respectful and call our office so we can work to reschedule you. If you arrive 15 minutes after your scheduled time, you will incur a $25 late fee/child.  Payment will be expected prior to rescheduling any appointments and is not reimbursable by your insurance.