Pediatric Care Agreement and Expectations Contract

Agreement Between [Practice Name] and Patient Family

This agreement outlines the mutual expectations and responsibilities between [Practice Name] and the parents/guardians of our pediatric patients.

Provider Responsibilities

We commit to:

• Provide high-quality, evidence-based medical care
• Maintain patient confidentiality according to HIPAA regulations
• Offer 24/7 emergency phone consultation
• Schedule sick visits within 24 hours when medically necessary
• Provide clear communication regarding treatment plans and follow-up care
• Respect cultural and personal values

Parent/Guardian Responsibilities

I/We agree to:

• Attend scheduled appointments or provide 24-hour notice for cancellations
• Follow the recommended vaccination schedule or sign appropriate waivers
• Notify the practice of any changes in contact information or insurance
• Call for prescription refills during regular office hours with 48-hour notice
• Pay copayments at the time of service
• Maintain respectful communication with staff

After-Hours Care

• Emergency phone: [Number]
• Call 911 for life-threatening emergencies
• After-hours calls are for urgent medical concerns only

Financial Agreement

• Insurance claims will be submitted by our office
• Parents are responsible for understanding their insurance coverage
• Outstanding balances must be paid within 90 days
• Payment plans available upon request

Termination Clause

This agreement may be terminated by either party with 30 days written notice, except in cases requiring immediate termination for safety concerns.

Parent/Guardian Signature

Date

Provider Signature

Date