This form collects all the necessary personal information for new patients.


This form advise you of your complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.


This form helps you to understand the differences between the types of visits and how deductibles, copays and coinsurance vary depending on the type of insurance you have.


This form authorizes our office to provide the person or entity you designate on the form with access to your protected health information (PHI).


This form collects information on your medical history that is important to your physician in decision-making, formulating a diagnosis and providing the right medical care for you.


This notice describes how medical information about you may be used and disclosed and how you can get access to this information.


This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices.



This form authorizes our office to release your medical records.


This form authorizes our office to see your child when they are brought in by someone else.


This form authorizes our office to release your prescriptions to someone other than you.


This form authorizes our office to provide the person or entity you designate on the form with access to your protected health information (PHI).


This form explains what a well check covers and does not cover.


This form collects updated information on your medical history that is important to your physician in decision-making, formulating a diagnosis and providing the right medical care for you.



We are doing everything possible to hold down the cost of medical care, and we agree to provide quality medical care at a fair and reasonable price. You can help a great deal by eliminating the need for us to bill you and by understanding the benefits of your insurance. The following is a summary of our payment policy.

Payment is required at the time services are rendered, unless other arrangements have been made in advance. This includes applicable co-insurance, co-payments and outstanding account balances. Reston Pediatrics Associates Physicians accept cash, personal checks, and VISA, MasterCard, American Express and Discover cards. There is a service charge for all returned checks.

If you receive more than one type of service on the same day, you may be responsible for more than one co-pay or the balance for the additional service, depending on your insurance plan (i.e.: well exam and a routine/ sick visit). Any amount not covered by the insured/ patients insurance is due upon receipt of the bill. Failure to pay balances may result in discharge from the practice.

Patients with an outstanding balance of $100 or are 45 days overdue must make arrangements for payment prior to scheduling appointments.

MEDICAID PATIENTS We are not contracted with Medicaid and CANNOT see patients that have Medicaid. If you have Medicaid or plan to apply for Medicaid, you will need to find a provider that accepts Medicaid insurance.

We will give you an estimate of the cost of the visit and payment is due at the time of service. Please see the Front Desk staff when checking out.

Our billing representatives are available to discuss payment arrangements with you,
Monday-Friday between 8.00am and 4.00 pm, at 703-450-8660, ext 2001.

Overpayments, credits, and unapplied credits on a patient account will be refunded upon written request to Reston Pediatric Associates from the responsible party within 30 days.
If you are enrolled in a managed care insurance plan, (i.e., HMO, PPO) you must verify that one of your doctor’s names is on your insurance card. If your insurance card does not list us as your Primary Care Provider (PCP) and denies payment, we will bill you for all services. There is often a window of opportunity for you to change your PCP- please check with your insurer for the correct timing of the change.

If your insurance requires referrals to see a specialist you must request the referral prior to your appointment. NO retroactive referrals will be given.

Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment, and 2 hours for same day sick visits. We will charge a $50.00 for missed appointments or same day cancellations. Should you miss more than two appointments and fail to cancel in advance, you may be discharged from the practice.

Just as we receive an “Explanation of Benefits” (EOB) with payment from your insurance company, you too should receive a copy from the insurer that will detail outstanding balances you owe us.

All bills for patient balances are mailed to the address of record. There is no provision for us to “magically” ascertain that we have the correct address. Therefore it is imperative that you update us with any and all changes to your account whether it is a change of address, phone number, insurance, etc.

On an occasion that our computer does not generate a statement for you of all monies owed or your bill has gone to an old address, we will assume that you have been notified by the EOB sent to you from your insurer. Any and all outstanding balances over 90 days with no payment activity, no attempt to pay or dialogue with our billing office may be turned over to our collection agency.

Please do not ignore these statements, please contact us to help you meet your obligations. If your account is sent to the collection agency, you may be discharged from the practice.

Returned Checks
There is a $30.00 fee for all returned checks.
Writing a “bad check” is punishable under law. We will mail a letter requesting that payment be made within 5 days after receipt. All obligations not honored within this time frame will be pursued through the applicable court and you will be discharged from the practice.

You must complete Reston Pediatrics Associates Authorization for the Release of Medical Information form prior to your records being copied. A fee is charged for this service, which conforms to State code. RPA does not benefit financially from this service.

School forms, camp forms, and all other forms are completed by a provider, who will take time to review the patient’s chart and provide the required information. There is a $20 charge per form and a $10 charge for each additional child per family with a cap at $50 for large families.

We participate in many managed care plans; we do not participate with Medicaid insurance at Reston Pediatrics Associates and CANNOT see patients that have Medicaid. However it is your responsibility to know whether your insurance has restrictions on the doctors you can see, or limits the services you can receive.

If you provide complete and accurate information about your insurance, we will submit claims to your insurance carrier as a courtesy to you. Depending on your insurance coverage, you may be responsible for co-payments, co-insurance, or other deductible amounts. Please verify with your insurance company the scope of your financial responsibilities are with respect to your contract for coverage with your insurance company. Your coverage is a contract between you and your insurance company. Co-payments are due at the time of service.

Please see the detailed list of plans, many plans require that you make a co-payment at the time of service. We accept cash, checks and most major credit cards at our office.

Please bring your insurance card with you for each visit and notify our front desk staff with any insurance coverage updates.

Please contact our billing office at 703-450-8660 Ext 2001, or call your insurance carrier should you have questions.

We accept most major health insurance plans including the following:

  • Aetna
    Aetna Innovation
    Allied Benefit Systems
    Anthem Blue Cross Blue Shield
    Anthem Health Keeper
    Assurant Health
    Carefirst Blue Cross
  • Compass Rose
    Core Source
    Foreign Service Benefit Plan
    Golden Rule
    Greatwest/Cigna PPO
    Meritain Health
  • One Net PPO
    Optima Health
    United Healthcare

We do NOT accept Medicaid, Anthem Health Keepers Plus or Kaiser Permanente.
For any other insurance plan please call our Billing office (703-450-8660 ext 2001) or call your insurance carrier.

Your insurance policy is a contract between you and your insurance carrier. Reston Pediatrics Associates Physicians are not a party to that contract. We MUST emphasize, that as your healthcare provider, our relationship is with YOU and not your insurance company.We will bill participating insurance companies as a courtesy to you. Nevertheless, YOU are responsible for payment regardless of your insurance company’s decision to deny coverage or to reimburse less than the allowable.You are expected to pay your co-payment and outstanding balances at the time of service.Your contract with your insurance company determines the amount of your co-pays and other patient responsibilities. Co-payment amounts are not always clearly indicated on your insurance card. It is your responsibility to know whether or not you have co-pay and to pay at the time of service. If our staff does not “ask” for your co-pay amount or if your co-pay is not clearly indicated on your insurance card, this is not considered a waiver of your contractual requirement with your insurance company to pay this fee nor is it construed as our waiver of acceptance of your co-payment at the time of service. Co-payments not paid by you at the time of service will be billed with an additional charge of $5.00 fee.If we have not received payment from your insurance company within 45 days of the date of service, you will be expected to pay the balance in full. You are responsible for all charges.Please understand the benefits your insurance provides for office visits. It is your responsibility to know what services are covered. If you are unsure, check with your employer or call your insurance company.As board certified Physicians, we follow guidelines established by the American Academy of Pediatrics for rendering appropriate, quality medical care regardless of the provisions you have with your insurance company. It is your responsibility to be aware of your insurer’s provisions for payments of office visits, hospitalizations, immunizations, well- child exams and routine medical exams including school, camp or sports physicals.Patients who arrive to be seen in our office with invalid/ terminated insurance, lack of proof of continuing coverage (new insurance pending), or the wrong doctor’s name on the card will be seen if payment for the visit is received at the time of service. It is the Parents responsibility to contact our office to provide insurance information once it becomes available.Please register your newborn with your insurer as soon as you are discharged from the hospital. Care for your newborn is not covered by your insurance until the baby is officially registered on your plan. Most insurance requires this to be done before your child is 30 days old. We will not schedule any well-child exams after the 2 month exam for patients with previous balances and/ or no verifiable insurance unless you are prepared to pay for the current exam in full and 50% of the outstanding balance on the account.The parent (s) or guardian (s) accompanying a minor is responsible for providing current insurance information for the minor as well as all associated payments due for any services provided.Parent (s) or guardian (s) must have an Authorization for Medical Treatment form signed for times when minors arrive unaccompanied for an appointment.Insurance claims may be denied because your insurance company has requested additional details from YOU. Examples are “Coordination of Benefits” (COB) Questionnaires and written requests for “accident information”. Your insurance company will not pay until you fulfill their request. Once again, the provisions of your insurance are between you and your insurer. In these cases, you will be billed for outstanding charges until the insurer receives the information from you, and you ask the insurer to process the claim and we are ultimately paid for our services.Our Physicians and Nurses focus their time and attention on patient care and will therefore defer all billing questions and or concerns to our billing office.Every plan must provide a complete description of its coverage, requirements, and limitations. This information is often available on your insurer’s website. Read it carefully and ask questions if there’s anything you don’t understand. We welcome the opportunity to discuss any aspect of our financial/ payment policies with you.


Immunization Information from American Academy of Pediatrics

Immunization Information from
American Academy of Pediatrics

Consumer Product Safety Commision

Consumer Product
Safety Commision

National Highway TrafficSafety Administration

National Highway Traffic
Safety Administration

Virginia Department of Health

Virginia Department
of Health

Centers for Disease Control and Prevention

Centers for Disease Control
and Prevention

Healthy Children

Healthy Children

Allergy & Asthma Network / Mothers of Asthmatics

Allergy & Asthma Network /
Mothers of Asthmatics





Please call or email us to schedule your meet & greet!

This form is for NON-MEDICAL communications only! If you have a question regarding your medical care, please call our office.



44160 Scholar Plaza Suite 450, Lansdowne, Virginia 20176