Forms & Policies

New Patient Forms

Completing our forms prior to your child’s first appointment will help expedite the check-in process. These forms may be completed on online and printed or printed and completed manually. Just bring them with you and present to our front office staff when you arrive for your appointment.

  • Patient Information Sheet – This form can be completed to include up to 5 children in the family.
  • Privacy Practices (HIPAA) – This policy outlines our privacy practices as it relates to the Health Insurance Portability and Accountability Act (HIPAA). This policy does not need to be brought with you to the appointment. It is for your information only and should be reviewed prior to signing the Notice of Privacy Practices – Patient Acknowledgement form.
  • Notice of Privacy Practices – Patient Acknowledgement – This form is to acknowledge you have received a copy of our privacy practices as they relate to the Health Insurance Portability and Accountability Act (HIPAA).
  • Financial Policy 2024 – This policy outlines our billing practices, handling of missed appointments, returned checks, and when payment of co-pays and outstanding bills are expected.
  • Authorization to Treat Minor Child Not Accompanied by Parent or Legal Guardian – This form can be completed to allow your child to be treated when accompanied by someone other than the parent or legal guardian or for a child to be treated unaccompanied by an adult.

Well-child Visit

Is your child 5 years of age or younger?

If you answered yes to this question, there is a screening tool we use called the Ages & Stages Questionnaire (ASQ). We use this tool to screen your child’s motor and language development based on their age. We also screen for autism and autism-related conditions around 18 to 24 months of age using the M-CHAT form.

The ASQ can take some time to complete, especially for older toddlers. For some questions you may need to have your child perform simple tasks to provide the most accurate answer – and we all understand how sometimes our children do not feel like performing those tasks the moment we ask them.

By completing the appropriate form within a few days prior to the appointment, it can be done in familiar surroundings and at a place and time where your child may feel more comfortable participating.

For the 18-month and 24-month well child visit: M-CHAT (autism screening)

Attention Deficit Disorder Forms

The providers at Eastern Pediatrics utilize the NICHQ Vanderbilt Assessment Scale for initial evaluation and follow-up of Attention Deficit Hyperactivity Disorder (ADHD).

The forms are broken out by informant (parent or teacher) and point in therapy (initial evaluation prior to therapy or follow-up on therapy)

You may print the needed form(s) from the links below.

Billing & Insurance

Eastern Pediatrics will work with you to help keep your health care costs as low as we possibly can. One way to accomplish this is to help eliminate excessive and costly billing. The information presented here is to help accomplish this.

At Appointment Check-In

Always bring your most current insurance card with you at the time of your visit. Please notify us at the time of check-in of any changes in address, insurance, telephone or contact information.

Please pay your co-pay and/or deductible at the time of service; or if you do not have insurance, please come prepared to pay for your visit in full.

Please check with your insurance company as to the participation status. If we are not in network with your insurance, we will be glad to file the insurance claim, but payment is expected at the time of service.

Payment Options

We accept cash, personal checks (in-state only), Visa and MasterCard. We do not accept post-dated checks. There is a $35.00 fee for all returned checks. Secure payments via credit/debit card can be made online by visiting our secure patient portal.


We are required by our insurance contracts to collect co-payments (if applicable) at the time of service. If not paid at the time of service, you will be charged a fee of $20.00 or more depending on your insurance company.

We participate with the following insurance companies:

  • Medicaid
  • Blue Cross and Blue Shield of North Carolina
  • United Healthcare
  • Aetna
  • Cigna
  • Medcost
  • Wellpath
  • North Carolina Health Choice
  • Atlantic Integrated
  • Tricare

We will be glad to bill your insurance company, but that does not guarantee they will pay us for the services we provide. Your account is ultimately your responsibility.

Managed Care-HMO Plans

If you are enrolled in a managed care insurance plan (HMO), you will need to obtain a referral/authorization from our office prior to seeing a specialist. We will not issue retroactive referrals, so you will need to get this prior to seeing a specialist.

Past Due Accounts

Balances not paid within 90 days are considered past due unless a payment plan has been arranged with our Financial Advocate in advance. Past due accounts will be turned over to a collection agency and will be reported to the Credit Bureau. Processing fees will be applied to the account. We reserve the right to terminate patients with bad debt.

Canceled, Late, and Missed Appointments

Canceled, late and missed appointments are very costly to our practice and to the other patients needing an appointment. We ask that you kindly give us a 24-hour notice when you need to cancel your appointment. We charge a $80.00 fee for missed or late cancellation of appointments. Continued excessive abuse of unfulfilled scheduled appointments may result in termination from our practice.

If you arrive 5 minutes or later beyond your scheduled appointment time for a well-child or same-day appointment, we reserve the right to cancel your appointment and a fee of $80.00 will be applied to your account.

Financial Difficulties

We realize that financial hardships may occur, and we will do our best to assist you with a payment plan, but we ask that you contact our Financial Advocate before your account becomes past due. We can discuss your financial situation and arrange a payment plan so that we can continue to provide care for your child or children when they need it. Please call our Billing Office between 9:00 AM and 4:30 PM Monday through Friday at 252-561-7777 if you need assistance or if you have questions regarding your account.

FAQ’s Regarding Billing and Insurance

What is a deductible?

A “deductible” is a specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims.

What is coinsurance?

Coinsurance is the amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if your insurance pays 80% of the claim, then you pay 20%.

What is an EOB (Explanation of Benefits)?

An explanation of benefits (commonly referred to as an EOB form) is a statement sent to you by your health insurance company that explains what medical treatment and/or services were paid on your behalf. An EOB typically describes or explains: the services provided, the date of service, the description and/or insurer’s code for the service, the name of the person or place that provided the service, and the name of the patient, the doctor’s fee, and what the insurance company allows (the amount initially claimed by the doctor or hospital, minus any reductions applied by the insurance company) and the amount the patient is responsible for paying.

My child has insurance, but I do not have my insurance card. Can my child still be seen today?

Yes, your child can be seen, but you will be considered “self-pay” for that date of service.

If I have to pay out-of-pocket and my insurance goes back retroactive and pays, will I be refunded?

If the Billing Office receives your insurance card within 45 business days, we can file the claim for reimbursement. Once the insurance has paid the claim, we will issue you a refund in the form of a check.

Can you bill me for my co-payment amount?

Yes, but you will be responsible for an additional $20.00 fee plus your co-pay amount. Please refer to our Financial Policy.

Can I be set up on a payment plan?

Yes, but payment plans are only available for account balances greater than $100.00. Please speak to our Financial Advocate to assist you with a payment plan.

Eastern Pediatrics, PA is committed to providing quality care to our patients with or without insurance coverage. If you are uninsured and having trouble finding resources to purchase insurance coverage, please let us know and our patient representatives and insurance department will be glad to suggest some options for you. The NCQA (National Committee for Quality Assurance) offers free information on their website for consumers on how to select a health insurance plan through the different marketplaces, and they also have accrediting and ranking information on different health plans at You can also visit This is the government health insurance marketplace set up to facilitate the purchase of health insurance in each state in accordance with the Patient Protection and Affordable Care Act (Obamacare).

Medical Records

When requesting your child’s medical records, a medical release form must be completed and returned to Eastern Pediatrics. For each individual child’s medical records, there will be a $25.00 processing fee.

Once the completed form has been received, our office will contact the parent or guardian when the records have been processed and are ready to be picked up or mailed. Please allow up to 2 weeks for processing.

The request form to transfer medical records can be found here.