Office Policies

Want to know an office policy, check here.
Call 704-717-2826 to make an appointment.

Requests for Medical Records

Requests for medical records must be made in writing and a processing fee of 75 cents per page for page 1-25, and 50 cents per page for pages 25-100 will be assessed. Payment can be made at the time records are picked up, otherwise when records are requested by an outside physician or medical facility, a bill for this fee will be forwarded to the guarantor's address of record. Immunization records and all medical records can only be released after a signed medical information release form has been submitted to our office.


Requests for form completion for daycare, school, camp, sports participation, etc. are best handled at the time of the visit. However, most forms can usually be completed if the child has had a physical within the past 12 months. We encourage you to utilize the patient portal to request and receive any forms that are not done at the time of the visit. We ask that you allow 24 hours for all forms to be completed, if not completed at the time of your visit. We strive to maintain updated shot records for your child on the patient portal which you can access free of charge at any time. There is a $10 administrative fee for printout of shot records in the office. Due to the complex nature of FMLA forms, they will be completed within 7 days. The administrative fee for this service is $25. Please include any specific details regarding your FMLA forms that you need included such as visits to hospitals or specialists with your request.

Patient Privacy

It is the policy of our practice that all physicians and staff preserve the integrity and the confidentiality of protected health information (PHI) pertaining to our patients. The purpose of this policy is to ensure that our practice and its physicians and staff have the necessary medical and PHI to provide the highest quality medical care possible while protecting the confidentiality of the PHI of our patients to the highest degree possible. Patients should not be afraid to provide information to our practice and its physician and staff for purposes of treatment, payment and healthcare operations (TPO).

To that end, our practice and staff will:

  • Adhere to the standards set forth in the Notice of Privacy Practices.
  • Collect, use and disclose PHI only in conformance with state and federal laws and current patient authorizations as appropriate.
  • Not use or disclose PHI for uses outside of the practice’s TPO, such as marketing, employment, life insurance applications, etc. without an authorization from the patient.

  • Treat all PHI data as confidential in accordance with professional ethics, accreditation standards, and legal requirements.
  • Not disclose PHI data unless the patient or legal representative has properly authorized the release or the release is otherwise authorized by law.
  • Recognize that although this practice “owns” the medical record, the patient or legal representative of the patient has the right to inspect and obtain a copy of his/her PHI. In addition patients have a right to request an amendment to their medical record if they believe their information is inaccurate or incomplete.

To that end our physicians and staff will:

  • Permit patients access to their medical records when their written requests are approved. If we deny their request, we must inform the patients that they may request o review of our denials. In such cases we will have an on-site healthcare professional review the patient’s appeal.
  • Provide patients an opportunity to request the correction of inaccurate or incomplete PHI in their medical records in accordance with the law and professional standards.
  • Maintain a list of disclosures of PHI for purposes other than TPO for each patient and those made pursuant to an authorization as required by HIPAA rules. We will provide this list to patients upon written request.
  • Adhere to any restrictions concerning the use or disclosure of PHI that patients or their legal representatives have requested in writing and have been approved by our practice.

All staff and physicians must adhere to this policy. Our practice will not tolerate violations of this policy. Violation of this policy is grounds for disciplinary action, up to and including termination of employment and or criminal or professional sanctions in accordance with our practice’s personnel rules and regulations.

Our privacy policy is subject to change at any time. Any changes will be effective upon the release of the revised privacy policy and will be made available to patients upon request.

Fees and Insurance Coverage

Payments of co-pays, deductibles and other patient portions are expected at check-in before any services are rendered. This includes any balances related to administrative fees due to missed appointments, late cancellation/rescheduling of appointments, and medical records. For your convenience, we accept cash, checks, Visa, MasterCard, Discover, and American Express. There is a $25 service charge for all returned checks.

You must bring a valid insurance card to every visit. Your insurance will be verified prior to each visit and if we are unable to verify active coverage, any and all fees for your services will be collected before any services are rendered. Insurance claims are filed with the participating plans where a valid insurance card is provided. You must report any insurance changes to the office as soon as possible. Any information that is inaccurate, or received after the date of service may not be billable to the insurance carrier, and may become the responsibility of the account guarantor.

When adding a newborn to your insurance plan, please check with your Human Resources department about requirements of your particular plan. If your child’s insurance coverage is not in place at your initial visit, payment will be collected before any services are rendered. Once you have received the child’s insurance card, bring it with you to your next appointment.

Many insurance policies require prior approval or authorization for tests, procedures, specialist referral visits or hospital admissions. While we try to determine and meet these requirements, we ask for your assistance as well in order to ensure timely filling and payment of insurance claims. It is the responsibility of the policy holder to know and understand these requirements in order to avoid any costly penalties and denials by your insurance carrier.

Missed Appointments

Missed appointments and late cancellations/rescheduling represent a cost to us, to you and to the other patients who could have been seen in the time set aside for you. We require at least a 24 hour notice for any cancellations or rescheduling of every appointment made. Failure to cancel or reschedule 24 hours in advance will result in a $25.00 administrative fee per appointment.

Medicaid Information

If you are a recipient of Medicaid, you must adhere to the policies of the Medicaid Program. We at Starks Pediatrics will only accept Medicaid patients with a valid, active recipient ID number, which we will verify before any services are rendered, or with a valid Medicaid Card. Our staff has no access to Medicaid Recipient ID numbers, unless provided by the parent/legal guardian. If the Medicaid recipient ID number is returned to us as Inactive, Unknown, Missing, Invalid, or Not Found for any reason, any and all charges will be collected before any services are rendered.

If your child is a newborn, and the Medicaid recipient ID number has not yet been processed, you can still see the physician, however any and all charges will be collected before any services are rendered, and will not reimbursed at a later date. It is our policy at Starks Pediatrics that we do not accept Medicaid Pending or Medicaid for Pregnant Women (MPW).

If your Medicaid recipient ID number or Medicaid card has another Physician/Facility listed as the Primary Care Physician (PCP), then you, the parent/legal guardian, must call your case worker and request that your PCP be changed to Starks Pediatrics for any future appointments. The staff of Starks Pediatrics cannot make this change for you. The Medicaid Program will only accept requests for changes in the PCP from the parent/legal guardian. While another PCP is listed on your card, Starks Pediatrics can not accept that card for services.

It is our policy at Starks Pediatrics that if your child has active Medicaid coverage and active private insurance coverage, under no circumstances are we allowed to accept or bill to the Medicaid policy. Co-pays and deductibles for the private insurance plan are not covered by the Medicaid Program and therefore will be collected before any services are rendered. Any claim denials from the Medicaid Program due to active private insurance coverage can prevent us from filing the medical claims to the private insurance in a timely manner, and can become the responsibility of the account guarantor due to non-compliance to the Medicaid Program and the private insurance policy.

The Medicaid Program does not cover any charges due to administrative fees. This includes the fees that are incurred due to late cancellation/rescheduling of an appointment, missing an appointment altogether, and print-outs of medical records. If you have any problems or questions related to the Medicaid Program Polices and Guidelines, you can call the Medicaid office at (704) 512-5555 or (888) 671-7437.

Delinquent Account

If a balance remains on your account beyond 30 days following the date of services rendered, regardless of pending insurance payment, it is considered delinquent and the account guarantor will become responsible for payment of the entire remaining balance prior to scheduling any appointments, unless arrangements have been made with our Billing Manager.

If your account is delinquent beyond 60 days following the date of services rendered, it will be turned over to a collection agency, you risk reporting of that information to national credit bureaus, all future appointments will be canceled and no further appointments will be scheduled until the balance of your account is paid in full. In addition, the account guarantor will be responsible for any collection’s and attorney’s fees and any cost or expense associated therewith. You will be dismissed from the practice if your account is placed into collections. No further medical service of any kind will be given to anyone with an account placed into collections, including telephone advice.

If you are in need of assistance or have any questions regarding your fees, payments or statements, please contact your insurance carrier first, and then contact Starks Pediatrics and ask for the Billing Manager. All questions related to billing will not be addressed by the physician during or after your appointment. Your physician’s role is to provide the best medical service possible and therefore, the full responsibility for billing concerns will be addressed with the Billing Manager before services are rendered. Should you have any comments or complaints regarding the Financial Policy or procedures that remain unresolved, please feel free to check out our website, and on the Contact Us page you can leave your comment or complaint.