Financial & Privacy Forms
Please download, read and sign our financial policy agreement and privacy notice.
- Vaccination Policy
- Financial Policy
- Appointment Policy
- After-hours Care
- Accepted Insurance
- Prescription Refills
- Office Forms
Vaccination Policy
Only patients who are fully vaccinated per the CDC recommended schedule will be accepted at La Petite Pediatrics.
Dr. LeJeune and Dr. Sicard would be happy to discuss a catch-up schedule for those patients currently delayed. An up-to-date immunization record is required for new patients prior to scheduling their first visit.
Financial Policy
Insurance
As a courtesy, our office will file the forms necessary for you to receive the full benefits of your medical coverage. We ask that you familiarize yourself with your insurance policy to be fully aware of any limitations of the benefits provided. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Insurance is a contract between you and your insurance company and/or your employer and your insurance company. Although our office will make a good faith effort to assist you in obtaining your benefits, it is at the discretion of your insurance company to pay for the services we provide.
Copayments & Deductibles
A copayment and/or deductible or coinsurance may be required at the time of service depending on your insurance policy. Payments are accepted in the form of cash, check, or credit card with a courtesy fee of 4%. We also accept Health Savings Account (HSA) cards.
Copayments are a contractual requirement from the insurance company and cannot be written off by our office. If you have a High Deductible Health Plan (HDHP) and have not yet paid your deductible in full, it is likely that any non-preventive services will require payment at the time those services are rendered. Coinsurance may apply even after meeting your deductible. Please see Health Insurance 101 for a better explanation of these terms.
Patients Without Coverage or Non-Covered Expenses
We are happy to work with families that prefer to pay directly for services or do not have insurance. For such patients, a time of service discount will be applied to the bill if settled in full on the day of service. This discount only applies the day of service. The same discount will be applied to any non- covered charges for patients with insurance, if paid at the time of service. This discount cannot be applied toward the “patient responsibility” portion of covered charges, as those charges are already discounted through the contract we maintain with your insurer.
Sick Complaints During a Well Child Check-Up
Insurance covers preventive care (wellness visits) as a bundled service. If you present to a scheduled wellness visit and your child is sick, or you’d like to address a chronic issue, our office is obligated to file a separate visit code with your insurance plan — just as we would if you brought your child in for that complaint on any other day. As such, your regular copay, deductible, and/or co-insurance amounts will apply, and payment will be expected at the time of service.
Appointment Policy
Visits are by appointment only. Patients who walk in without a scheduled appointment will be offered the next available slot. Same-day sick visits are guaranteed if you contact the office by 12pm.
Your “check-in” time is always 10 minutes prior to your appointment time. This is to allow time for you to update your family’s information and complete any required forms, such as developmental screening tools or cardio risk forms for athletes. Arriving early ensures that Drs. LeJeune and Sicard can see you – and everyone else scheduled that day – on time.
You will receive appointment reminders by text, email, and/or phone calls. All appointments scheduled more than two days in advance must be confirmed, or they will be released.
Appointments scheduled same or next-day are considered confirmed at the time of booking.
Same-day responses to emails and text messages through one of our secure messaging methods are guaranteed if the message is received by 2pm. Please note, you may be asked to schedule a same-day or next-day appointment to follow-up.
Late Arrivals
- Patients arriving more than 10 minutes past their appointment time will be offered a later appointment for the same day, if available.
- Patients arriving more than 20 minutes past their appointment time will be considered “no-show” and will be assessed any relevant fees.
- Three “no-shows” or same-day cancellations per family may result in dismissal from the practice.
Cancellation Fees
- Appointments cancelled less than 24 hours. prior to the appointment time will be charged a $25 fee
- No-show appointments will be charged a $50 fee
- Returned checks will be charged a $50 fee, in addition to any late fees accrued
After Hours Care
When La Petite Pediatric Clinic is closed, you have several options. For life-threatening emergencies, always call 911. You may want to look here for common answers to common complaints, as well as a dosage table for common anti-fever medications.
Please note that medications will never be called in after hours.
If you have an urgent medical questions about your child and did not find the answer at the suggested links above:
24-Hour Nurse Line
We recommend first to utilize the nurse line on the back of your health insurance card. This is a free service.
Call (337) 366-8616
For a true after-hours emergency that requires you to speak to the doctor on call, call our office number and choose the prompt to be connected with the doctor on call. For non-emergent issues, you may be assessed a $25 fee for utilizing this service.
Urgent Care
We always prefer that you contact us before going to any urgent care or emergency room, as we may be able to save you a trip. However, if your child needs urgent medical treatment, we suggest that they be seen by a dedicated pediatric provider
Accepted Insurance Plans
Many plans are actually owned by larger companies, so even if not listed, there is a good chance we ARE in-network with your employer-based medical insurance. Please call us if you do not see your plan listed.
- Aetna HMO
- Aetna PPO
- Aetna Better Health
- Amerihealth Caritas Louisiana
- Blue Cross/Blue Shield
- Cigna HMO
- Cigna PPO
- Humana
- Healthy Blue
- Louisiana Healthcare Connections
- Multiplan
- PHCS PPO
- Tricare
- UnitedHealthcare
- Unitedhealthcare Community Plan
Please note: It is the responsibility of the policy holder to know what services are covered by your insurance healthcare plan and what your responsible portion is for each service.
Prescription Refills
If your child needs a refill, please call the office and leave a message for the nurse. Same-day refills can only be guaranteed if your child meets the criteria below for date of last visit and you call by 12pm.
Medications can not be changed nor dosages adjusted without an in-office visit.
**Separate visit means your child was seen for this complaint alone, not in combination with another complaint or a well-child visit.
- ADHD and Behavioral Health medications
Require a separate visit within the past 90 days. - Asthma, allergy, and eczema medications
Require a separate visit within the past 4 months. - All other chronic medications
Require a separate visit within the past 6 months.
Office Forms
New Patient Forms
Please download and complete this packet of forms in preparation for your first visit. Complete one set for each new patient.
Pre-Visit Questionnaires
Save time, complete visit forms online
CHADIS is our online system that delivers developmental and health questionnaires directly to parents and families. The questionnaire results are sent directly to your doctor at La Petite Pediatric Clinic.
This information will help us address any concerns about your child’s health and development. Completing the questionnaire ahead of time also saves you time in the office!
You should complete CHADIS questionnaires:
- The very first time your child visits our office
- Before every well-child visit
- Before all ADHD, asthma, and behavioral health visits
Instructions
The first time you use CHADIS, you will select No, I have never used CHADIS before. Save your login information, and the next time you’ll select Yes, I have used CHADIS before.
CHADIS will save your child(ren)’s name and birthday, and will only offer you age-appropriate questionnaires. You will have one login per family, and multiple children can be assigned.
When you reach the screen Reason for using CHADIS, please select well-child for all routine check-ups. For other visits, select the appropriate choice. If this will be your child’s very first time visiting our office, please be sure to select the New Patient visit type — either well-child for a check-up, or other visit for everything else.
Please send us an email if you have any problems registering or choosing the correct appointment type.
Financial Privacy Forms
Please download, read, and sign our financial policy agreement and privacy notice.
Financial Policy Agreement
Notice of Privacy Practices (English)
Notice of Privacy Practices (en Español)
Self-Pay Agreement
School Forms & Records
Forms for school, camp, or sports will be completed as a courtesy if presented at the time of a visit. All other forms will be assessed a $10 fee per form.
Forms that must be completed in less than 3 business days may be assessed an additional $10 rush fee.
Vaccine records will always be provided at the time of a well-child visit for free, but will be assessed a $5 fee, when requested at other times.
Office Hours
Mon: 8:00am – 5pm
Tue: 8:00am – 5pm
Wed: 8:00am – 5pm
Thu: 8:00am – 5pm
Fri: 8:00am – 12:00pm
Phone: 337.366.8616
200 Beaullieu Drive
Building 7
Lafayette, LA 70508
Fax: 337.366.8133
After Hours Care
When the office is closed, you have several options. Always call 911 for a true medical emergency.