Insurance & Forms Print


Office services and hospital charges are determined by the level of services received. Co-pays are due at the time of service. A late fee will be assessed when a copay is not received at time of service. If we are not providers of your insurance, full payment is due at the time of service. Upon request, a claim form will be provided to assist you in filing to your insurance company for reimbursement.

If your insurance company requires a referral for specialty services or tests, please call our office prior to your scheduled appointment and ask to speak to the referral person.

In order to wisely use your insurance, it is important that you understand which services your insurance plan covers and what it does not cover. Unfortunately, insurance plans vary from employer to employer and some insurance plans change yearly. Sometimes it can be very difficult to keep up with or to understand your plan benefits. To find the answers, consult your insurance plan policy book, call the benefits number listed on your insurance card, or contact your employer’s human resource office.

Insurance questions to ask prior to seeking medical care:

  • When is the policy effective?
  • Which family members are covered by the policy?
  • What is required to add a new family member to a policy?
  • Which doctors can I see on my plan?
  • Is my doctor on this plan?
  • What “network” does my plan use?
  • Which labs/hospitals are in my network?
  • Are all the doctors in a particular office/hospital in my network?
  • How much is my copay?
  • How much is my deductible?
  • How much co-insurance will I owe?
  • Does my policy cover well care?
  • For what ages?
  • Is there an annual limit?
  • Does my policy cover immunizations?
  • How much?
  • Which immunizations?
  • Are there age limits?
  • Is preventative care part of my deductible?
  • Does my copay apply to preventative care?
  • How do referrals work?

Important Insurance Terms

  • Co-pays: the flat fee paid by plan members at each time of service. This fee applies to specific medical services. Co-pays are collected at each visit.
  • Co-insurance: the amount of money paid out of pocket by plan members for medical services. Payments usually are a fixed percentage of the total cost for a medical service covered by the plan.
  • Deductible: this is the sum of money that an individual or family must pay out of pocket for medical expenses before a health plan begins to pay for services.
  • Preferred provider: many insurance plans make contracts with certain doctors, hospitals, and other medical providers. Choosing a preferred provider means that an insurance company will pay a higher percentage of your medical costs.


New Patient Forms

New Patient Packet (PDF)

Common School and Daycare Forms

IHSAA Physical Evaluation Form

FSSA Child Care Form (49969)

Medical Records Release Form

Please email completed medical records request forms to This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Be sure to complete one form for each patient and to clarify if the patient(s) are transferring out of Meridian Pediatrics to a new primary care doctor.

Please allow up to 30 days for completion of requests.

Medical Records Release Form (PDF)

Telemedicine Forms

Telemedicine Acknowledgement Form (PDF)

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Now Accepting Insurance Cards by E-mail

You can provide us with a copy of you insurance card by email! Please take a picture of the front and back of the insurance card and send it to:

This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Please include your child's name, date of birth, and the policyholder's name in your email.

Please understand that this email address is STRICTLY for insurance card submissions. Do NOT email any other information. Thank you!