Middletown Pediatrics
Louisville, Kentucky



- If you are unable to keep an appointment, we require 24 hour notice. There is a charge of $25.00 for all Sick "No Show" and a $50.00 charge for all Check-up "No Show" visits.

- If you are more than 15 minutes late for your appointment, it may be necessary to reschedule.

- A $50.00 fee will be charged for any checks returned for insufficient funds. This will not be billed to your insurance and is your responsibility.

-Designated Alternate Guardians may accompany patients for acute visits only and must comply with all office policies and procedures.  

Alternate Guardian Form


Office Policies



- It is your responsibility to understand your benefit plan with regards to covered services, (including well exams and immunizations), participating laboratories and referral requirements.

- All applicable deductibles, co-insurance and co-pays ARE DUE AT THE TIME OF SERVICE.

- Self-Pay patients are expected to pay for services IN FULL AT THE TIME OF SERVICE.

- For all scheduled non-emergent appointments, patient due balances MUST BE PAID PRIOR TO YOUR VISIT.



- It is your responsibility to know if a written referral or authorization is required to see specialists, whether pre-authorization is required prior to a procedure, and what services are covered.

- A 3-5 business day notice is required for all non-emergent referrals and specialty follow-up appointments.

- It is your responsibility to know if a selected specialist participates in your plan.

- It is the sole responsibility of the parent, guardian, or designated alternate guardian bringing the child in for services to pay all co-pays, deductibles or balances at the time of service and to provide a current copy of the child's insurance card. Failure to do so will result in rescheduling. In situations involving divorce, custody arrangements or court ordered financial agreements, it is the parents'/legal guardians' obligation to work out an agreement themselves through the court system without the inclusion of Middletown Pediatrics.