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Patient Info & Links


The following information is provided to inform you of our policies and procedures.

Here you will find a selection of useful forms to have at your disposal.


Hospital Affiliations:

Our physicians have privileges at Johnston-Willis and Chippenham and at Bon Secours St. Francis Medical Center. The ONLY Pediatric Emergency room is located at Chippenham Hospital.

Record Release Policy:

If, for any reason, you require a copy of your child's medical records, a written release form must be completed with our office.

Referral Policy:

If you are in need of a referral, please call our office within 48 hours in advance of specialist appointment at 804-744-4495 and select Option 4. Please contact your insurance carrier to find out if a referral is required.

The information you will need when you call:

  • Patient name (please spell last name)
  • Patient date of birth
  • Insurance company name and identification number
  • Specialist name (please spell last name)
  • Specialist phone/fax number
  • Diagnosis (reason for specialist visit)
  • Appointment date and time

This process will prevent any failure of an insurance company to provide the benefit and the payment for the specialist visit.

Prescription Refill Policy:

If you have a prescription that needs to be refilled, please call our office at 804-744-4495 and select Option 3.

If you would like us to call the prescription in to your pharmacy, please have the pharmacy name and phone number. Please note that not all refills can be called in. If you are required to come to the office to pick up the prescription, you will be required to fill out a prescription pickup form. Please allow up to 48 hours to process this request.

If you require medications for long-term maintenance of conditions (asthma, allergies, and behavioral medication, etc.), it is recommended by the AAP and the AMA to have a medication check performed every six months, and a physical performed annually.

Cancellation Policy:

Appointments must be cancelled at least 24 hours prior to the appointment time. Failure to do so will result your being marked as a “No Show”. If there are extenuating circumstances regarding your cancellation, please let us know so we can handle your cancellation accordingly.

“No Show” Policy:

We as an office prepare for your child’s visit. It is very important when you schedule an appointment to keep it. Our physicians only have limited time slots during the day to see our patients. By not keeping a scheduled appointment, our physicians' ability to provide service to other patients is limited. As a result, in the event you cancel an appointment without giving 24 hours notice, or fail to come to your scheduled appointment, you will be marked as a “No Show”.

In the event you are counted as a “No Show” to an appointment, a letter will be sent out to you stating the appointment you missed, and reminding you of our policy. If you are a 'No show' to three or more appointments in a one-year period, your relationship with our practice may be terminated.

Joining Our Practice:

Thank you for choosing Chesterfield Pediatrics as your child’s primary care provider. To help make your transition easier, simply print and complete the Record Transfer Release form. We will receive either by fax, mail, or in person. We will handle the process of obtaining your records.

Record Release Policy:

If, for any reason, you require a copy of your child's medical records, a written release form must be completed with our office. There is a fee of $0.50 per page for the first 50 pages and $0.25 thereafter.


Links

Recommended Medical Websites: