Forms & Insurance

The Childrens Clinic of Nashville

New Patient Forms

If you would like to expedite your visit with us, please download and complete the forms found below.

You may either bring the completed forms with you to the first visit, or mail them to us before your appointment.

Patient Consent for Use And Disclosure Of Protected Health Information - PDF Form

Patient Health history form - PDF Form

Get Adobe Reader

Payment and Collection Policy

Insurance and Payment
You will be required to pay your co-payment or deductible in full at the time of your visit. No co-payments or deductibles will be billed. We accept cash, personal check, money order, debit card, Visa, or MasterCard. Our returned check fee is $40.00. If there are two returned checks on your account, all future payments must be by cash, credit card, or money order. If you do not have healthcare coverage, you will be required to pay in full at the time of service unless payments arrangements have been made prior to your appointment. Our office staff will help answer specific questions regarding our participation with your health plan.

As a courtesy to our patients, we will file your insurance. In all cases, the patient is responsible for the total balance. If your insurance refuses payment for any service, you will be required to pay in full for the service to our office and negotiate with your insurance company for any reimbursement. Your insurance company can answer your policy’s payment coverage.

After insurance payments have been made, any unpaid or remaining account balances on the patient's account must be paid within 30 days unless prior arrangements have been made with our billing personnel. The billing number is (615)297-6151. Unpaid balances exceeding 60 days are subject to interest charges, and balances exceeding 90 days may be turned over to our collection agency. The patient will be responsible for all collection, attorney fees and court costs. If an account has been in collections, any subsequent & additional non-emergent services will be on cash or credit card basis only.

Missed or No-show Appointment Charge
Our office requires 24-hour notice of cancellation. If proper notice is not given, we reserve the right to charge a $25.00 no-show fee to your account. Unavoidable extenuating circumstances will be considered on a case¬-by-case basis, and the patient’s physician will make the final decision concerning the assessment of the cancellation fee.

Forms and Letters
Our office requires a minimum of 3 business days to complete all forms: school forms, camp forms, disability forms or letters requested by parents or required by the patient's insurance. There is a $20.00 fee for copying an entire medical record. If the medical record is in storage, the charge is $30.00 for the entire record and $15.00 for immunization records. All fees must be paid when forms are picked up. Due to privacy regulations, no forms can be faxed or mailed. Please contact our office for all questions or concerns.

Insurances Accepted

We are contracted with the following insurance plans. Please check below to see if your plan is listed. (All insurance plans are subject to change)

  • Aetna
  • Amerigroup
  • Assurant Health
  • Blue Cross/Blue Shield
  • Cigna
  • Coresource
  • Healthspring
  • Humana

… and several other health insurance providers

If your insurance is not listed, please contact our office.

subscribe now!
4322 Harding Pike, Suite 313
Nashville, TN 37205
(615) 297-9541
Check out our facebook page