Forms & Policies

Office Policies, Downloadable & Secure Forms

Food and Drink (Updated 09/28/16)

In the interest of safety for our food allergic patients, we have instituted a policy of no food or drink being brought into the clinical area of our office.    Thank you for respecting this new policy.

Financial Policy

Williamsville Pediatric Center (WPC) requires payment at the time of service.    If WPC participates in your health plan, applicable co-payments will be collected at the time of registration.   Some insurance companies also require deductibles or pay percentages (co-insurance).   You are responsible for the payment of these patient responsibility portions at time of registration.


All co pays are required at time of registration. Patients who do not pay their co pay at time of service, will also incur a $10 surcharge in addition to their co pay.

Self Pay (no insurance)

Patients who seek treatment without insurance will be required to pre-pay an estimated amount of $70 for office visit services.   Pre-collection amounts are estimates only as we are unable to determine services performed prior to being seen. You will be billed for any remaining amount due or refunded should you overpay.

Non-participating/Non-contractual Insurance Plans

Should WPC not participate with your healthcare plan you will be required to pay pre-estimated amount of $70 for office visit services.  Pre-collection amounts are estimates only as we are unable to determine services performed prior to being seen. You will be billed for any remaining amount due or refunded should you overpay, after your bill is processed by your insurance company.

Deductibles & Co-insurances

Some insurance plans require the patient to pay a portion out-of-pocket before paying for services.   Patients with deductible or coinsurance plans are required to pay pre-estimated amounts at the time of registration.   Prepayments are $70 for office visit services. Pre-collection amounts are estimates only as we are unable to determine services prior to being seen. You will be billed for any remaining amount due or refunded should you overpay after your bill is processed by your insurance company.

Late Arrival (Updated 6/15/15)

If you are going to be more than 5 minutes late for your appointment, we request that you call our office. If you arrive more than 15 minutes after your appointment time, the appointment will be cancelled and rescheduled. We work diligently to stay on schedule and ask that you arrive 15 minutes prior to your appointment time to allow time for any necessary paperwork..

Clinical Visit Summaries (Updated 5/17/13)

A short summary of your office visit is available within 24 hours after your visit and may be requested at any time. Please check with our receptionist if you would like one.

Insurance change (Updated 5/8/13)

Child Health Plus through BlueCross in Genesee and Niagara counties will be transitioning to Fidelis. If you are affected by this, be sure to choose one of our doctors as your PCP (primary care provider) if required at sign-up.

Form Fees (Update 4/04/14)

Due to the staff time involved, Williamsville Pediatrics charges $10 for physical form completion. If you bring forms with you to your well visit/physical appointment, it will be completed free of charge.

Williamsville Pediatric Center Vaccination Policy (Update 3/10/2014)

Download this and other Forms here.

After Hours charges (Updated 3/4/13)

For the convenience of our patients, and at the urging of local health insurance companies, Williamsville Pediatrics is open Monday through Thursday until 8:30pm. Each urgent office visit after 5pm during the week and also on Saturday mornings carries an "after hours" co-pay charge from your insurance company. If you have a "high deductible" type insurance plan, you may be responsible for this charge. Please check with your health insurance plan for the details of your coverage.

Age of patients (Updated 4/21/11)

Williamsville Pediatrics sees patients from birth up until their 20th birthday.

No-show Fees

If you cannot make a well child visit, you must cancel 24 hours or greater in advance. If you do not show or cancel, a $25 fee will be charged to your account.

Lab Orders

Different insurance companies use different lab companies exclusively, and sometimes will not pay if you are sent to the wrong lab.

Please note that you are responsible for familiarizing yourself with your insurance carrier requirements.

Quest Diagnostics is the most commonly used lab in our area, and we will most likely be sending you there.

Williamsville Pediatric Center is not responsible for charges incurred if your insurance company does not participate with that lab.

After hours phone calls

The Lifetime Health Nurses Line will be closing. Our physicians will be taking ALL CALLS after hours.

Please limit calls to EMERGENCY QUESTIONS ONLY. All routine and non-urgent calls should be directed to the office during office hours.

Information regarding many typical topics of concern are available on this web site under "Parent Resources".

If you do have an urgent need to speak to a doctor after hours, our answering service number is 827-3536. Please allow up to one hour to receive a call back from the covering physician.

Developmental Screening

Our office follows the AAP recommendation to do routine screening for autism at 18 and 24 months.

Please be aware that your insurance may no longer be covering this service. While you may have a "zero co-pay" for well visits, this may not apply to all parts of the visit.

Alternative shot schedules

All patients using alternative shot schedules will need to see a provider (doctor or NP) for each visit involving shots, which depending on your insurance, may incur a co-pay that you will be responsible for at the time of the visit.

This is for your child's safety and to make sure they get the correct vaccine.

Co-pay collections

Starting March 1, 2009, we will be collecting the co-payment prior to your visit. If you are unable to pay the co-pay at that time, there will be a $10 service charge.