Village Pediatrics, LLC
Office Policy

Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal. Please read each section carefully and initial. If you have any questions, do not hesitate to ask a member of our staff.



  1. We value the time we have set aside to see and treat your child. We do not double book appointments. If you are not able to keep an appointment we would appreciate 24 hr notice. There is a charge of $25 for missed appointments.
  2.  If you are late for your appointment (>15 minutes) we will do our best to accommodate you. However, on certain days it may be necessary to reschedule your appointment.
  3. We strive to minimize any wait time, however emergencies do occur, and such will take priority over a scheduled visit. We appreciate your understanding.
  4. Before making an annual physical appointment, check with your insurance company whether the visit will be covered as a healthy (well child) visit.

Insurance plans: Please understand:

  1. It is your responsibility to keep us updated with your correct insurance information. If the
    Insurance Company you designate is incorrect, you will be responsible for payment of
    the visit and to submit the charges to the correct plan for reimbursement.
  2. If we are your primary care physician, make sure our name or phone number appears on your card. If your insurance company has not yet been informed that we are your primary care physician you may be financially responsible for your current visit.
  3. It is your responsibility to understand your benefit plan with regards to covered services, participating laboratory, etc. For example:
    1. Not all plans cover annual healthy (well) physicals, sports physicals or hearing and vision screenings. If these are not covered, you will be responsible for payment.
    2. For children less than 2 years of age there is a limit as to the # of allowable well visits per year. If the # of visits is exceeded, your Insurance Company will not pay; therefore you will be responsible for payment.
  4. It is your responsibility to know if a written referral or authorization is required to see specialists, whether or not pre-authorization is required prior to a procedure and what services are covered.



  1. Advance notice is needed for all non-emergent referrals, typically 3-5 business days.
  2. It is your responsibility to know if a selected specialist participates in your plan.
  3. Remember we must approve referrals before they are issued.


Financial Responsibility:

  1. According to your insurance plan, you are responsible for any and all co-payments, deductibles and coinsurances.
  2. Co-payments are due at the time of service. A $10 service fee will be charged in addition to your co-payment if the co-payment is not paid by the end of that business day.
  3. Self-pay patients are expected to pay for services in FULL at the time of the visit.
  4. If we do not participate in your insurance plan, payment in full is expected from you at the time of your visit. We will supply you with an invoice that you can submit to your insurance for reimbursement.
  5. Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits (EOB). Your remittance is due within 10 business days of your receipt of your bill.
  6. If previous arrangements have not been made with our finance office, any account balance outstanding greater than 28 days will be charged a $10 re-bill fee for each 28 day cycle. Any balance over 90 days will be forwarded to a collection agency.
  7. For scheduled appointments, prior balances must be paid prior to the visit.
  8. If you participate with a high-deductible health plan, we require a copy of the health savings account debit/credit card or a copy of a personal credit card to remain on file.
  9. We accept cash, checks, Visa and Master Card credit and debit.
  10. A $25 fee will be charged for any checks returned for insufficient funds.



  1. There is no charge for a blue and yellow form given at the time of your child’s visit. This is
    considered part of the visit. However, should you lose your forms there will be a $5 charge
    ($3 for one form) to replace them.
  2. Any additional school, camp or sport forms are subject to a $5 per form fee. Payment is due when the forms are dropped off. We require 3 day turnaround time for forms.


Transfer of records:

  1. If you transfer to another physician we will provide a copy of your immunization record
    and your last visit to your physician, free of charge, as a courtesy to you.
  2. A copy of your complete record is available for a $1 per page fee.
  3. We provide records of your child for visits (including consults from specialists) rendered here at Village Pediatrics only. For any previous records, you must request a transfer of records from your previous doctor(s).


Prescription refills:

  1. For monthly medication refills, we require 48 hours notice, during regular business hours.
    Please plan accordingly.


If you have questions concerning our Terms of Service or Office Policy please contact us using the information below. 

Village Pediatrics
319 West Town Place
St. Augustine, FL 32092
Phone: 904-940-1577
Fax: 904-940-1916