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Policies & Forms
Cancelled or Missed Appointments
We request a 24-hour advanced notice to cancel or reschedule an appointment. If three scheduled appointments are missed without adequate notification or cancellation, this may result in termination of care for your child and his or her siblings.
Prescription refills are provided as a convenience to our patients who are up-to-date on well visits and adhere to recommended follow-up schedules for conditions such as ADHD and asthma. Most prescription refill requests will be completed within 3 business days. Prior Authorizations or other request for information from insurance providers may delay the request. For routine medication refills, please contact your pharmacy. We do not accept phone refill requests during evening and weekend hours. As a rule, we will not call in antibiotics without first examining your child, as this is not consistent with good medical care.
Fees & Bills
Co-pays and deductibles are due at the time services are rendered. These payments are dictated by your insurance carrier, not by Burlington Pediatrics. We participate in many insurance plans and will file insurance claims on your behalf. If we do not participate in your insurance plan, we ask that you pay at the time of service and we will provide you with a form for you to file for your benefits. Due to continuous changes in insurance policies, we ask that you bring an updated insurance card to each visit.
If you are uninsured or self-pay, we will help to defray medical costs by offering a 10% discount if payment is made in full at the time of your visit.
If your child is born at or admitted to Alamance Regional Medical Center, our office will file your insurance claim. Any charges or balances not covered by your insurance will be billed to you. If payment has not been made by your insurance carrier within 30 days, payment then becomes your responsibility.
Our insurance specialists are pleased to assist you with any billing inquiries. Please contact us at 336-228-8316.
Your payment and personal information submitted through our online payment portal is safe. Our Secure Sockets Layer (SSL) software is the industry standard and among the best software available today for secure commerce transactions. It encrypts all of your personal information, including credit card number, name, and address so that it cannot be read over the internet.
Refunds for overpayments made through our online payment portal are processed once a month.
To make a payment on your account, click here.
Health Information Privacy
If you are transferring care to our practice, please complete the Medical Information Release Form. We will need your signature and the complete name and address of the previous practice before we can process your request. Your child’s medical records at Burlington Pediatrics are confidential under HIPAA law and will not be released to anyone without written consent. We charge a fee to copy records for attorneys, insurance companies, and for personal use. Please allow at least 48 hours processing time.
Emergency Room Visits
We urge you not to use the Hospital Emergency Room for anything except a true medical emergency. You may wait many hours to be seen by a provider who does not specialize in children, all the while exposing your child to dangerous germs. Your child’s medical needs are better met by our physicians who are familiar with your child’s medical history and can follow-up on illnesses. If you are uncertain, call our office before taking your child to the Emergency Room. After-hours, call our Nurse Line at 984-974-6303 for advice.
We believe in vaccines! Vaccines are safe. Vaccines do not cause autism. One of the most important ways we can protect your child’s health and the health of our community is to vaccinate against deadly, preventable diseases. If you would like to discuss vaccines, our physicians welcome any questions or concerns. We follow the standard immunization schedule as recommended by the American Academy of Pediatrics and the Centers for Disease Control. We do not advocate alternative vaccine schedules, since there is no proven benefit. Any delays will only place your child at unnecessary risk. If you choose not to vaccinate, we ask that you find another healthcare provider whose medical philosophy is compatible with your views. Please view our Vaccine Policy for more information.
Burlington Pediatrics Forms
Burlington Pediatrics/Mebane Pediatrics Information Sheet
Pediatric History Form
Policy Information Sheet
Medical Information Release Form
Patient Registration Form (17 and Younger)
Patient Registration Form (18 and Older)
Code of Kindness
Reach Out and Read Survey
Reach Out and Read Consent Form
Well-child and Physical Forms
M-CHAT Developmental Form
(Complete no greater than 1 week prior
to the 18-month and 24-month visits)
9 – 14-Month Ages & Stages Questionaire
15-Month Ages & Stages Questionaire
36-Month/3-Year Ages & Stages Questionaire
PEDS Response Form
Daycare Physical Form
Kindergarten Assessment Form
Kindergarten Assessment Form (en español)
NC High School Athletic Association Sports Physical
School Medication Forms