healthy kids care

am the parent or legal guardian of the patient listed above. I authorize Healthy Kids Care (HKC) to use and share my child’s protected health information (PHI) for the purposes of treatment, payment, and healthcare operations. These activities include providing medical care, billing insurance, and managing office operations.

At Healthy Kids Care at Sunrise, our mission is to provide safe, evidence-based medical care for infants, children, and adolescents. One of the most important ways we protect the health of our patients and the community is through routine childhood immunizations.

Healthy Kids Care at Sunrise is a pro-vaccine pediatric practice. We strongly believe that routine childhood immunizations are essential for maintaining the health and safety of all children in our care.

Important Practice Policy

Our providers believe vaccines are safe, effective, and necessary for protecting children and the community.

If a parent or legal guardian chooses to decline recommended vaccines or does not wish to vaccinate their child, we respectfully recommend that the family seek care with another pediatric provider whose policies better align with their preferences.

This policy helps ensure we maintain a consistent standard of preventive pediatric care for all patients in our practice.

❌ Frequent No-Shows / Policy Compliance

Repeated missed appointments or failure to comply with office policies may result in limitations on future appointment scheduling. Continued failure to keep scheduled appointments or comply with office policies may result in dismissal from the practice, in accordance with office policy and applicable regulations.

Vaccine Scheduling Options

We understand that parents and guardians may have questions regarding vaccines. To support families while maintaining safe medical care, our office offers the following options:

Please note that choosing a split schedule may require additional visits to complete all recommended immunizations.

Cancellation / Rescheduling / No-Show Fee Policy

We respectfully request that parents or guardians notify our office in advance if an appointment needs to be canceled or rescheduled. If a patient fails to attend a scheduled appointment (no-show) or the office is not notified 24 hours prior to the appointment time, a $25.00 missed appointment fee is applied.

If a parent or guardian states they contacted the office to cancel or reschedule, proof of the call or communication may be requested. If the office is unable to verify the cancellation or rescheduling, the $25.00 fee will remain the responsibility of the parent/guardian.

***The appointment fee will be due at the patient’s next scheduled visit.***

Forms & Administrative Fees

Forms such as sports physicals, school forms, FMLA paperwork, and newborn screening documentation must be presented at the time of the appointment. Form fees, ranging from $25–$60, are due at the time of service. Requests submitted after the appointment will still incur a form fee and may require the patient to schedule a return visit, depending on the date of the most recent annual wellness exam (typically within the last 6 months), as determined by the provider.

Patient Financial Responsibility & Insurance Billing Policy

As a courtesy, our office will submit claims to your insurance carrier for services rendered. However, insurance coverage is a contract between you and your insurance company. Payment from your insurance company is not guaranteed, and coverage may vary depending on your specific plan benefits.

am financially responsible for any chargesnot covered or paid by my insurance, including but not limited to deductibles, copayments, coinsurance, and non-covered services. If my insurance company does not pay the claim within a reasonable time or denies payment, the balance will become the responsibility of the patient or guarantor.

Authorization to Release Medical Records (Office Request)

Above listed patient authorizes the following healthcare facility to make record disclosure:

Hipaa Authorization Statement

I understand that I may revoke this authorization at any time by submitting a written request to the medical office listed above, except to the extent that action has already been taken in reliance on this authorization.I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. This authorization will expire one (1) year from the date of signature unless otherwise specified here:

I understand that this authorization may include disclosure of information relating to mental health treatment, HIV/AIDS testing, genetic testing, or substance use treatment unless otherwise limited in writing.

I certify that I have read and understand this authorization and voluntarily agree to the release of my medical information as described above.