Policies & Forms
Learn about the policies that help us provide your children with the very best of care.
Online Patient Forms
For your convenience, you can complete our secure forms online. Questions about which forms you might need? Please call our office and we will assist you in preparing for your child’s visit.
New Patient Forms
- To help expedite your child’s first visit, please complete these forms before you arrive for your appointment.
- New Patient Information
- Health History
- Financial Agreement
- Consent to Share Patient Information
- Acknowledgement of HIPAA Privacy Notice
- Medical Records Release of Information
- Well-Child Visit FormIf your first appointment is a check-up, please complete the age-appropriate Well-Child Visit Form (available on this page).
Established Patient Forms
Screenings
- PHQ-9Depression Screening
- PHQ-9 for TeensDepression Screening
- GAD-7Anxiety Screening
School & Sports Forms
Well-Child Visit Forms
- Please complete the age-appropriate form before your child's Well Visit. If your child is between ages, select the form younger than their age. For example, if your child is 21 months old at the time of the visit, complete the 18-month form.
- Newborn
- 2-4 Week
- 2 Month
- 4 Month
- 6 Month
- 9 Month
- 12 Month
- 14-15 Month
- 18 Month
- 2 Year
- 30 Month
- 3 Year
- 4 Year
- 5 Year
- 6 Year
- 7-8 Year
- 9 Year
- 10 Year
- 11-14 Year (Parent)
- 15-17 Year (Parent)
- 18+ Year (Patient)
- Transition to Adult Care Notice
For Office Use
Insurance & Billing
Our main focus is to provide first class medical care to our patients. In order to do this, we must receive prompt payment. Our financial policy has been developed:
- To meet our financial obligations
- To follow terms set by insurance contracts
- To help you understand your financial responsibilities for the services we provide
If you have any questions concerning these policies, please contact our office.
Your Responsibilities
- To know the limits and coverage of your health insurance policy.
- To ensure that one of the doctors at Shoreline Pediatrics is assigned as your primary care physician, if required by your insurance policy.
- To pay any copayments or deductibles at the time of service.
- To show your child’s current insurance card and your photo ID at each visit.
- To provide updated address, phone numbers, and insurance information to our office.
We Accept Most Insurance
In order to be as accessible as possible to the families in our community, we accept most major insurance plans, including Priority Health and Meridian Medicaid. We do not accept United Health Care.
If you have any questions about the plans we accept, please call our office.
Office & Appointment Policies
Appointments Are Required
Patients are seen by appointment only, so please call ahead even if you feel your child needs to be seen right away. We will make every effort to see sick patients on a same-day basis. Well child visits should be scheduled in advance.
Please call our office to schedule your child’s appointment anytime during our normal business hours.
Mutual Respect of Time
We strive to stay on schedule. Although there can be emergency situations that prevent us from running on time, we pledge to provide quality care with minimal wait time to the best of our ability.
- Please be considerate and call us before your appointment if you are not able to attend or if you are running late. Missed appointments represent a cost to us, you, and to other patients that could have been seen during the time set aside for your child.
- You may be asked to reschedule if you are late for your appointment.
- Cancellations are required 24 hours prior to any well visit appointment and two hours prior to any sick visit appointment via phone call to the practice.
- Any appointment cancelled less than 24 hours in advance may be marked as a missed appointment.
- If you miss more than 3 appointments without calling ahead of time, you may be discharged from the practice.
Medication Refills
If you are in need of a medication refill or require a prior authorization for a medication, please call the office and leave a message on the medication refill line.
- Medication refills may require an associated “med check” visit. For controlled substances (ie ADHD medications), med checks are required every 3 months.
- Please call 72 business hours prior to running out of your prescribed medication.
- Prescriptions will be sent to the preferred pharmacy on file with the office unless otherwise requested by the assigned account holder.
Specialist Referrals
Most insurance plans require a referral from your primary care provider in order to see a specialist. Please call our office. We will usually need to schedule an office visit to assess the situation and refer you appropriately.
Records and Form Requests
To obtain a copy of your medical records, please complete this Records Release Form.
- The first copy is free. For subsequent copies there is a $25 fee.
- For other forms such as FMLA, SSI, etc., there is a $25 fee due in advance.
- All forms require 5 business days.
Health Appraisal/Sports Physical Forms
- If you require a health appraisal or sports form and have had a well visit with a Shoreline Pediatrics provider within the last year, you may request one by filling out the appropriate form’s first page. This portion is required to be completed by a parent or guardian (or patient over 18) before a doctor will sign and return it to the patient portal.
- Forms requested outside of a well visit require 5 business days for completion.
Patient Privacy
Shoreline Pediatrics physicians and staff are governed by and comply with the federal Health Insurance Portability and Accountability Act (HIPAA). We are required to abide by the terms of our office Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at the time.
- A copy of our current HIPAA statement is available upon request.
- Patients age 18 and older are required to sign a waiver authorizing parental access to their account. Parents of patients over the age of 18 will not be permitted to access any medical or billing information without written consent of the patient.
- By Michigan state law, patients 11 and up need to authorize their parents to have access to their electronic medical records.
After-Hours Care
If your child’s illness or injury is life threatening, dial 911.
Otherwise, for urgent matters that cannot wait until business hours, call our office to be connected to a physician or a pediatric-trained triage nurse.
Shoreline Pediatrics does not endorse using national drug store chains for vaccinations or urgent care clinics for sports physicals. We believe your child’s medical home is the best place for all acute care, preventative care and immunizations. Come see us!
Poison Control Hotline
(800) 222-1222
Suicide & Crisis Lifeline
Dial/Text/Chat 988
www.988lifeline.org
Health Education Tools
- AAP Patient Education LibraryBrowse this library of expert advice from the American Academy of Pediatrics.
- Medication Dosage CalculatorBe confident that you are treating your child with the correct dose of Tylenol, Motrin, or Benadryl. We can guide you on how much to give, based on your child’s weight.
- Reliable WebsitesOur recommendations for accurate online resources you can depend on.
Walk-In Clinic
Our Walk-In Clinic is closed for the season. Please call our office to make an appointment for your child.
Tue, Wed, Thu
8:00 am - 8:30 am
We will not accept walk-ins after 8:30 am.
Appointments are on a first-come, first-served basis and only for new, acute or urgent concerns such as fever, ear pain, sore throat, UTI, etc. Established patients only.
We cannot address any chronic issues/conditions at this walk-in clinic.
- Our Walk-In Clinic is ideal for fever, ear pain, sore throat, infection, etc.
- Chronic or long-term concerns such as ongoing cough or pain, constipation, feeding concerns, eczema, acne, or migraines will require a scheduled appointment with your provider.
We Are a Vaccinating Practice
Shoreline Pediatrics requires that all of our patients are immunized according to the current vaccine schedule recommended by the American Academy of Pediatrics. All potential new patients must be up to date, or willing to get caught up with their vaccines. We do not accept new families that do not vaccinate their children. Please do not hesitate to contact our office with questions.
Resources
- Immunization ScheduleAmerican Academy of Pediatrics (AAP)
- Vaccine Information Statements
- Vaccine Education CenterChildren's Hospital of Philadelphia
- Vaccine Safety: The FactsAmerican Academy of Pediatrics
- VaccinateYourFamily.orgHelping to protect people of all ages from vaccine-preventable diseases
- Institute for Vaccine SafetyJohns Hopkins Bloomberg School of Public Health
- Centers for Disease Control (CDC)
- Immunize.orgFormerly Immunization Action Coalition (IAC)