Policies & Forms
Policies & Forms

Policies & Forms
Policies & Forms

Policies & Forms

Learn about the policies that help us provide your children with the very best of care.

Forms &
Downloads Billing &
Insurance Office Visits
& Services Immunization
Policy

Office Forms & Downloads

New Patient Forms

To expedite your first appointment, please complete these forms online prior to your first appointment.
New Patient Intake PackageAll patients need to fill out this form as completely as possible. All of this information is important for us.
Release of Medical RecordsThis form allows us to get records from your previous doctors. We need to have received your previous records before scheduling an annual check up appointment.
Financial PolicyOur office policies related to how we bill you and your insurance for services that are provided.
Notice of Privacy PracticesOur office policies related to the privacy of your child’s medical records.
Acknowledgement of Receipt of Privacy PracticesFor patients UNDER age 18.
Acknowledgement of Receipt of Privacy PracticesFor patients OVER age 18.
Over 18 Consent to Release InformationThis form is for young adults over the age of 18 that gives consent for our staff to speak with parents in regards to health information. Without this form, we can only share health information with the patient.

Patient Record Forms

Service & Treatment Policies

Privacy & Legal Policies

Billing & Insurance

We are committed to providing the best possible care and service to you and your child. We appreciate your understanding that your financial responsibilities are an essential part of your child’s care. If you have any questions concerning these policies, please contact our office.

Read Our Complete Financial Policy Pay Bill Online

Your Responsibilities

It is your responsibility:

To know the limits and coverage of your particular health insurance policy.
To show your insurance cards to us at each visit.
To pay your copay at the time of service.
To ensure that one of the physicians in our office is assigned as your Primary Care Physician (PCP) if you have an HMO policy.

Our billing staff will do their best to assist you with insurance questions. However, if you have questions about your coverage, it is best to check directly with your insurance company. We are happy to give you any information that will help you do this.

Accepted Insurance

Tamalpais Pediatrics accepts a variety of insurances, including employer provided and individually purchased plans. We also participate in most plans available on the Covered California Health Insurance Exchange. Please call our office for the most up-to-date information about insurance plans we accept.

HMO Plans
We are members of the Meritage Medical Network and Hill Physicians and participate in HMO plans through these networks. You must have a Tamalpais Pediatrics doctor assigned as your Primary Care Physician (PCP). Please give your insurance your pediatrician’s name and our address to ensure correct PCP assignment.
Non-HMO Plans
Please give your insurance or the insurance you are considering your pediatrician’s name and our address to confirm that your primary care physician participates in your specific plan.
Partnership HealthPlan of California (Medi-Cal)
We accept Partnership HealthPlan of California (Medi-Cal) for existing patients only. Your child must be assigned to our office through Partnership HealthPlan.
Private Pay or No Insurance
Full payment is required at the time of service.

Copayments & Deductibles

All copayments, deductibles, and charges not covered by your insurance company are your responsibility. Copays are due at the time of service. You are responsible for knowing your copay amount. Coinsurance and deductibles will be billed once those amounts are determined. Prompt payment of balances is appreciated. Our business office staff is always available to assist you with any insurance or billing issues and to answer any questions you may have.

Unpaid Bills/Collections

Bills unpaid for more than 90 days may be turned over to a collection agency unless other arrangements have been made. Accounts that are turned over to collections may result in dismissal from the practice.
If special circumstances make immediate payment impossible, payment arrangements may be approved by our Business Office staff.

Missed Appointments

Unless canceled at least 24 hours in advance, there may be a charge for missed appointments. Please help us serve you better by keeping scheduled appointments. Multiple missed appointments may result in dismissal from the practice.

Office Visit & Service Policies

Appointments

We make every effort to meet the needs of our patients by offering preventive well child visits, as well as same-day urgent care appointments when at all possible. Please contact the office to schedule a visit.

Our providers strive to stay on schedule. Although there can be emergency situations that prevent us from staying on schedule, we pledge to provide quality care with minimal wait time to the best of our ability. In order to respect your time, we make the following requests:

Appointments are required. Please arrive early or on time for your appointments. If you arrive more than 15 minutes late, we may have to reschedule your appointment or squeeze you into a different time slot.
If you plan on having additional children seen at your appointment, please let us know in advance so we can better accommodate them.
We require at least 24-hour notice on all cancellations. Unless canceled at least 24 hours in advance, there may be a charge for missed appointments. Please help us serve you better by keeping scheduled appointments. Multiple missed appointments may result in dismissal from the practice.

Service & Treatment Policies

Learn More About Our Services

ADHD Treatment

Your child’s health and success are very important to us at Tamalpais Pediatrics. Our goal is to provide the best possible care for children with ADHD and behavioral health conditions.

Children with ADHD sometimesoften require specialty care by a child psychiatrist or behavioral-developmental pediatrician. Some children can be diagnosed and followed here in our office by the pediatricians at Tamalpais Pediatrics. Your child’s pediatrician will work with you to decide if it is appropriate for our team them to help with diagnosis and management of your child’s ADHD.

If you would like your child’s pediatrician to help with diagnosis or management of ADHD, please call to schedule a visit to discuss this with your child’s pediatrician. If your child is being managed by us, you will be required to read our ADHD Policy and provide a signed copy to the office. This policy also covers management of follow up visits and prescriptions for ADHD medications, which are controlled substances.

Teen Visits

Adolescence is an important transition from childhood to adulthood. During these years, patients will be offered and encouraged to have a portion of the visit alone with their provider. We try to pay special attention to the personal needs, confidentiality and privacy of our adolescent patients. During these visits, we will discuss issues such as alcohol, smoking, substance use and sexual activity. Patients may schedule appointments through their late teens and college years.

To learn about what to expect during your teen’s visit, take a look at our Guide to Your Teen’s Visit.

After age 18, patients are legally considered adults and need to give their written permission for us to speak with their parents.

Travel Consultations

If your child or family is traveling overseas, they may require vaccines or medications in order to stay healthy. Our Travel Visit Policy and Pre-Travel Consultation Form includes important information about insurance coverage and what you can expect from a travel visit. So that we can provide the correct treatment and advice, please complete forms for each child at least three weeks prior to travel. After your forms have been submitted, our team will review the information and reach out to you to schedule an appointment.

Vaccines save lives.

The pediatricians of Tamalpais Pediatrics strongly support vaccination of all children according to the CDC schedule of vaccines recommended by age. The Tamalpais Pediatrics Immunization Schedule is based on the CDC schedule. Our pediatricians have close to 200 years of combined experience in caring for children, and many of us have seen vaccine-preventable diseases firsthand. None of us wants a child to suffer from one of these illnesses, especially if it can be prevented by a safe and effective vaccine.

Measles and pertussis outbreaks continue to occur both nationally and locally, and we know that there will be vaccine-preventable disease outbreaks in the future. Tamalpais Pediatrics develops vaccine policies based on the most up-to-date evidence and a desire to protect our patients and community.

Delaying vaccines leaves children vulnerable to dangerous and deadly diseases for longer than necessary. When parents split up or delay vaccines there may be errors in timing of vaccines, and a non-recommended schedule may not be as effective as the CDC recommended vaccine schedule that we follow.

Our pediatricians have developed a vaccine policy to ensure that all of the children we care for are fully protected against vaccine preventable diseases.

A newborn’s first series of vaccinations (first DTaP, Hib, PCV and IPV) must be completed by 4 months of age.

The following vaccines must be given by the age listed.

Diptheria, Tetanus, and Pertussis (DTaP)
3 doses before 24 months of age, 5 doses before 6 years of age
Hemophilus Influenza, type B (Hib)
3 doses before 12 months of age, 4^th dose before 24 months of age
Pneumococcus (PCV)
3 doses before 12 months of age, 4^th dose before 24 months of age
Hepatitis B (Hep B)
3 doses before 6 years of age
Inactivated Polio (IPV)
3 doses before 24 months of age, 4^th dose before 6 years of age
Measles, Mumps, Rubella (MMR)
1^st dose before 24 months of age, 2^nd dose before 6 years of age
Varicella (VZV or chicken pox)
1^st dose before 24 months of age, 2^nd dose before 6 years of age
Tetanus, Diptheria, and Pertussis (Tdap)
1^st dose before 13 years of age
Meningococcal (MCV4)
1^st dose before 13 years of age, 2^nd dose before 18 years of age

Additional visits due to a non-recommended schedule will require a visit with a physician. This may incur a co-pay.

The pediatricians at Tamalpais Pediatrics encourage you to keep your child up-to-date on vaccines. If your child is not up-to-date, please schedule an appointment to have your questions answered and have your child’s vaccines updated. If your child requires more than one set of vaccines, we will work with you to create a catch-up schedule.

If your family refuses to meet our minimum requirements, we will help you find another health care provider outside of our practice to care for your child. If you have any questions about this policy, please discuss them with your child’s pediatrician.

Immunization Resources

Larkspur Office

5 Bon Air Road, Suite 105
Larkspur, CA 94939

Map & Directions

Phone
(415) 461-0440

Fax
(415) 461-3792

Novato Office

251 Vintage Way
Novato, CA 94945

Map & Directions

Phone
(415) 892-0965

Fax
(415) 461-3792

Office Hours

Monday - Friday
8:30 am - 5:00 pm
Closed for lunch

Saturday - Sunday
Closed

Appointments

To schedule an appointment for your child, call either office during business hours or send a request through your child’s patient portal account.

We are committed to seeing your child the same day if you feel they should be seen. During office hours, the advice nurse is available to answer any questions you might have.

Learn More