top of page
Concrete Wall

Policies & Forms

Health Information Privacy

Under Federal Law, you have rights when it comes to your health information. Please review detailed information in our Notice of Privacy Practices. For more information, see the U.S. Department of Health and Human Services website.

Notice of Privacy Practices

Aviso de Prácticas de Privacidad (en Español)

Practice Policies

We ask that all patients and families abide by our practice's policies to ensure a positive experience through mutual understanding and aligned expectations. Please review our Policy Information Sheet for further details. 

Policy Information Sheet

Carta de Información de Burlington Pediatrics (en Español) 

Code of Kindness

Divorce, Separation, Foster Care, & Custody Agreements Policy

Important Billing Information for Well Visits

Vaccine Policy

We believe in vaccines! Vaccines are safe. Vaccines do not cause autism. One of the most important ways we can protect your child’s health and the health of our community is to vaccinate against deadly, preventable diseases. If you would like to discuss vaccines, our physicians welcome any questions or concerns. We follow the standard immunization schedule as recommended by the American Academy of Pediatrics and the Centers for Disease Control. We do not advocate alternative vaccine schedules, since there is no proven benefit. Any delays will only place your child at unnecessary risk. If you choose not to vaccinate, we ask that you find another healthcare provider whose medical philosophy is compatible with your views. Please view our Vaccine Policy for more information.

Medical Records

If you are joining our practice, please complete the Medical Information Release Form. We require that we receive your child's medical records before scheduling your first appointment.

We request that you regularly update your information with our practice.

Patient Demographic Form

Formulario Demográfico del Paciente (en Español)

Your child’s medical records at Burlington Pediatrics are confidential under HIPAA law and will not be released to anyone without written consent. We charge a fee to copy records for attorneys, insurance companies and personal use as permitted by NC law. Please allow for up to 5 business days for processing time. 


There is also a $25.00 charge to complete FMLA forms.  All other forms not completed at the time of the visit will be a $10.00 charge. Please allow for up to 5 business days for completion.

Commonly used forms for daycare, sports participation, or medications for school are available at our office. These include:

Daycare Health Form

NC Health Assessment Form (for kindergartners or new students)

NC High School Athletic Association Sports Form

Alamance-Burlington School System Medication Authorization Form

Guilford County Medication Authorization Form

Orange County Medication Authorization Form

Fees & Billing

Co-pays and deductibles are due at the time of your visit. These payments are set by your insurance plan, not by Burlington Pediatrics. If we do not participate in your plan, we ask that you pay at the time of service and we will provide you with a form for you to file for your benefits. Please bring an updated insurance card to each visit. If you are uninsured or self-pay, we offer a 10% discount if payment is made in full at the time of your visit. Any charges or balances not covered by your insurance will be billed to you. If payment has not been made by your insurance plan within 30 days, payment then becomes your responsibility. Our insurance specialists are available to assist you with any billing inquiries. Please contact us at 336-228-8316. 

Important Billing Information for Well Visits

Cancelled or Missed Appointments

We request a 24-hour advanced notice to cancel or reschedule an appointment. If three appointments are missed within a 12-month period without adequate notification, this may result in dismissal of care for your child and his or her siblings.

Prescription Medication Refills

For your convenience, we offer several ways to request medication refills:

  • Portal Requests: Medication refill requests can be made through your child's portal account.

  • Phone Messages: You may leave a detailed message on our phone system when prompted for medication refills.

  • Pharmacy: You may request that your pharmacy send our office an electronic request.

  • At Your Visit: You may also request medication refills at the time of your visit. 


Medication refills are provided as a convenience to our patients who are up-to-date on well visits and adhere to recommended follow-up schedules for conditions such as ADHD and asthma. Please allow for 3 business days when requesting medications. Prior Authorizations or other actions from insurance plans  may delay the request. As a rule, we will not prescribe antibiotics without first examining your child, to ensure appropriate medical care.

If you or your child receives ADHD medication management through our practice, please review our Information for Patients and Families on ADHD Medication Shortages.

Medical Records
Fees & Billing
Cancelled or Missed Appts
Rx Refills
Health Infomaton
Practice Policy
Vaccine Policy

Burlington Pediatrics

530 West Webb Ave

Burlington, NC 27217

(336) 228-8316

bottom of page