VAS Payment Form

PEDIATRIC ASSOCIATES OF AUSTIN

Value Added Service Fee Payment Form March 1, 2025 - February 28, 2026
Read more about the Value Added Service Fee here:
Parent's Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
List Additional Children Here
Who is your preferred provider?*
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Benefits of Joining Our Practice

Open Saturday and Sunday mornings for urgent care appointments.

E-Prescribing to your pharmacy both new and refilled prescriptions when appropriate so medication may be ready when you arrive there.

Ability to access our patient portal to communicate securely with our staff.

No charge for completion of forms for child-care centers, schools, sports and camps. (There will be a charge for same-day form completion.)

An in-house lab is available at your convenience with “while you wait” results. Every time your doctor makes the correct diagnosis the first time because the lab is right here, you pay only one co-pay.

Finger-stick technology used whenever possible—outside labs such as Clinical Pathology labs do not use finger-stick technology but rather collect blood by venipuncture (out of the arm).

Ability to e-mail our office staff for appointment requests, for questions about insurance and billing, to send in school and camp forms and have us send them back to you.

Pediatric nurses available seven days a week including all holidays. Advice given during regular business hours for free and available after hours for a $25.00 fee. As always, the on-call physician supports them.

Our On-call team will minimize unnecessary visits to the emergency room or urgent care center where they do not know your children or their medical information. This can save you hundreds of dollars on unnecessary high copayments and facility fees.

Documenting with an electronic health record system that is designed specifically for the practice of pediatrics.

Our own full-service website with American Academy of Pediatrics approved medical Information.

Value Added Service Fee Payment*

1 Child

$117.00

2 Children

$211.50

3 or more children

$238.50

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Our goal is to provide comprehensive, high quality medical care to your family.
We are honored to be your family’s medical home!

I want to maintain a relationship with my pediatrician’s office and understand that in order to prevent services from being reduced or eliminated, an annual value-added service fee will be charged.

I agree and accept the annual fee for these value-added services. These services are not covered or required under my managed care plan. If you are experiencing a financial hardship, we will work with you so you can remain in our practice.

To pay by phone or set up a payment plan, call 512-814-1600.
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PEDIATRIC ASSOCIATES OF AUSTIN

SCROLL TO THE BOTTOM OF THE FORM TO SUBMIT AND ADD PAYMENT INFORMATION

Benefits of Joining Our Practice