Well Check Consent

Well Child Check Consent

Child's Name *

First Name Last Name

Date of Birth *

Child's Name (2)

First Name Last Name

Date of Birth (2)

Date

Child's Name (3)

First Name Last Name

Date of Birth (3)

Date

Child's Name (4)

First Name Last Name

Date of Birth (4)

Date

Thank you for bringing your child in for a well visit today. El Paso Pediatric Associates requires regular well visits (also known as preventive exams or physicals) per the AAP guidelines. We are providing this document to help you understand the difference between what is covered within a well visit and what is not. This form is simply a way to be as transparent as possible about what services we provide during each well check. We follow evidence based medicine using Bright Futures Guidelines.

Screening – During well visits, we perform recommended screenings appropriate to age and seek to uncover any conditions that may lead to sub-optimal health in years to come. In our experience, some insurance plans cover these screenings and cover the costs, some recommend the screenings but push costs to patient deductible/co-insurance, and some completely ignore the screening and not cover at all. We do not know in advance what will and will not be covered. 90% of the time, these screening tools are covered. It is your responsibility to understand what screening services are covered by your individualized insurance plan.

Screening	CPT Code
Edinburgh PostPartum Screening (every well check through 6 months)	96161
Ages & Stages Questionnaire (Development screening) *	96110
MCHAT (Modified Checklist for Autism in Toddlers) (18mos, 2 years)*	96110
GoCheckKids vision test * (May not covered by Insurance) (WCC at 6 months until they can use the chart)	99174
Lead & TB Exposure Questionnaire (6mos, 9mos, 12mos, 18 mos, yearly from 2 years)	96160
Dental Evaluation & Fluoride Protection(until dentist is established) (6mos and 9mos even with no teeth)	99429, 99188
Hearing and Vision Screening (yearly starting at 4 years)*	92551, 99173
PHQ-9 Depression Screen (yearly starting at 11 years)*	96127
CRAFFT Substance Abuse Questionnaire (yearly starting at 11 years)*	96160

Screenings with an Asterisk * are billed at a flat rate of $25

Insurance Coverage of Well Visits vs Problem-Oriented Visits – Well visits may uncover or revisit problem-oriented issues that require evaluation or management (ex. Ear infection, ADD concerns, wart treatments, lactation counseling). In compliance with insurance company billing policies, this then prompts charges for both categories. While preventive services may not require co-pay/deductible, problem-oriented services do prompt a co-pay/deductible/co-insurance.

If you need further explanation about incurring additional fees for services provided during your visit today, please ask to speak with our billing team.

Acknowledgment of Wellness Services Billing Procedures

I acknowledge that during my child’s well visit, there may be a problem-oriented service performed in addition to the wellness services. I understand that two separate charges may be submitted to my insurance company. Alternatively, I understand I may choose to return for a separate visit to address problem-oriented issues, at which time, my co-pay/deductible/co-insurance would still apply. I have reviewed the codes for my child’s well visit and understand that some of the screening tools may go to my deductible/co-insurance. I have been informed of the routine procedures performed during my child’s well visit.

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