Pediatrics 5280 Forms & Policies

Before your appointment with us, quickly and conveniently access patient forms from our practice.

Download Patient Forms

For each new patient you will need to complete and submit a Registration Form, a Billing/Financial form, an Office Policies Form, and a Medical History Form (based on age).

All forms are available to download.  To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com.

ASQ Developmental Questionnaires are no longer available on our website.  If you have a child age 2 months to 5 years, please arrive 10-15 minutes early for your child’s well child check appointment to complete the questionnaire.

Make a Payment Online

Your payment request will be processed within 24 hours, during normal business hours, Monday – Friday, 8:00 am – 5:00 pm, excluding holidays. If you do not receive confirmation of your request within 48 hours, please contact our office at 303-779-5437.

Pay Your Bill Online

Practice Policies

• General and Financial Policies
• Notice of Privacy Policy
• Fifteen Most Commonly Provided Services
• No Surprises Act

Late Patients

If you are more than 15 minutes late for a well-child visit, you will have to reschedule for another day/time.

If you are more than 15 minutes late for a sick visit, we will do our best to work you back into the schedule; however, there may be a wait.

Walk-In Patients

Pediatrics 5280 does not accept walk-in patients. Visits are by appointment only. The only exception is a nurse visit for flu shots during specified times of the year.

Add-On Patients

Please do not ask to have your other children seen during a sibling’s appointment. If you have additional concerns about another child, please schedule that child their own appointment.

Nurse Visits

Visits may be scheduled with a nurse for immunizations and certain lab draws if approved/ordered by one of our providers.  All other patient evaluation requires a visit with a provider.

After Hours Phone Calls

Please limit calls after hours to emergency questions only. All routine and non-urgent calls should be directed to the office during regular office hours. There is information regarding a wide variety of illnesses and concerns, as well as many OTC medication dosages on this website under Parent Information and Is Your Child Sick.

Daycare/Camp/School/Sports Forms

We are happy to fill out forms that you may need for your child that require a provider signature.  However, HIPAA laws prevent us from being able to fax them directly to your child’s daycare, camp or school. A child’s well child care must be current/up to date based on recommended schedule for providers to sign forms.

ADHD/ADD Follow up and Refills

•  Most ADHD/ADD medications (Concerta, Vyvanse, Adderall, Focalin, Ritalin etc.) are controlled medications.  Standing refills are not legal on controlled medications.
•  We are willing to write a 3 month mail-in prescription if you confirm your insurance will cover it.
•  Only your child’s primary care physician will authorize refills or new prescriptions for a controlled medication.
•  Please request your prescription at least one week before it is needed.  There is no such thing as an emergency refill on ADHD/ADD medications.  Your child will likely go without medication if you wait too long to request a refill.
•  Any child who is on ADHD/ADD medications is required to follow up in the office with their primary care physician at least every 3-6 months; more often if they are encountering difficulties.
• Changes in medication or doses may require an office visit.

Non-Discrimination Policy

In accordance with all applicable State and Federal Laws, Pediatrics 5280 does not discriminate against patients on the basis of race, color, national origin, sex, disability or sexual orientation.  We do, however, only care for patients up to age 22, which is based on the nature of our pediatric medical practice.

Pediatrics 5280 Non discrimination

Notice of Rights and Protections Against Surprise Medical Billing

Starting January 1st, 2022, The No Surprises Act ensures when you receive emergency care or are treated by out-of-network providers at an in-network hospital or ambulatory center, you have certain protections from surprise/balance billing.

What is “balance billing” (sometimes known as “surprise billing”)?

When you see a health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

Under the No Surprises Act, you are protected from balance billing for:

Emergency services 

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections.

Certain services at an in-network hospital or ambulatory center 

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill and may not ask you to give up your protections.

If you receive other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up those protections. You’re never required to give up your protections. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

Good Faith Estimate

Starting January 1, 2022, providers and facilities must provide a good faith estimate of expected charges for items and services to an uninsured (or self-pay) individual if requested.

• The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided together with the primary item or service.
• You may request a good faith estimate for a visit by calling our office at (303) 779- 5437.

Your Responsibility

Pediatrics 5280 does not provide emergency services. It is your responsibility to check with your insurance if we are in-network, and what is covered, when receiving care in our office.

If you believe you’ve been wrongly billed, please contact our office. If you have questions about your rights under this law, you may contact:

1. https://www.cms.gov/nosurprises/consumers
2. HHS, in coordination with the Department of the Treasury, Department of Labor and the Office of Personnel Management, has a telephone line for individuals to submit complaints regarding potential violations of the No Surprises Act. Call: 1-800-985-3059