Forms & Insurance

New Patient Forms

If you would like to expedite your visit with us, please download, print, and complete the forms found below.

You may either bring the completed forms with you to the first visit, or mail them to us before your appointment.

Patient Consent for Use And Disclosure Of Protected Health Information – PDF Form

Patient Health history form – PDF Form


Payment and Collection Policy

Insurance and Payment

The Children’s Clinic of Nashville has a credit card on file payment system. You will be asked for a credit card (or debit card) at the time you check in, and the information will be held securely on an offsite gateway. When your portion of the bill is determined (following a review of your copay, co-insurance, and deductible), we will charge your credit card, and a copy if the receipt will be emailed to you. Likewise, if a refund is owed to you, we will credit your card and send an email receipt.

This is an advantage to you since you will not have to write out and mail us checks. It is an advantage to us as well since it will eliminate the statements that we have to generate and mail out. The combination benefits everybody in helping to keep the cost of health care down.

The security of our patients’ information is always a top priority for us. After careful evaluation, we chose a company that we felt would be the best to store your data and to process the transactions. This company will also give us rapid support from a designated local agent who understands our system and concerns. This in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment.

You will be required to pay your co-payment at the time of your visit. If you do not have healthcare coverage, you will be required to pay in full at the time of service unless payments arrangements have been made prior to your appointment. Our office staff will help answer specific questions regarding our participation with your health plan.

As a courtesy to our patients, we will file your insurance. In all cases, the patient is responsible for the total balance. If your insurance refuses payment for any service, you will be required to pay in full for the service to our office and negotiate with your insurance company for any reimbursement. Your insurance company can answer your policy’s payment coverage.

Our billing number is (615)297-6151. Unpaid balances due to invalid credit card information are subject to interest charges, and balances exceeding 30 days may be turned over to our collection agency. The patient will be responsible for all collection, attorney fees, and court costs.

Missed or No-show Appointment Charge

Our office requires 24-hour notice of cancellation of scheduled appointments. If proper notice is not given, we reserve the right to charge a no-show fee to your credit card. Unavoidable extenuating circumstances will be considered on a case-by-case basis, and the patient’s physician will make the final decision concerning the assessment of the cancellation fee.

Forms and Letters

Our office requires a minimum of 3 business days to complete all forms: Immunization forms, school forms, camp forms, disability forms or letters requested by parents or required by the patient’s insurance. There is a $10 fee for form completion. Some forms may incur a higher fee based on complexity. There is a $20.00 fee for copying an entire medical record. If the medical record is in storage, the charge is $30.00 for the entire record and $15.00 for immunization records. All fees will be billed to the credit card on file when forms are picked up. Due to privacy regulations, no forms can be faxed or mailed. Please contact our office for all questions or concerns.

Insurances Accepted

We are contracted with the following insurance plans. Please check below to see if your plan is listed. (All insurance plans are subject to change)

  • Aetna
  • Amerigroup
  • Assurant Health
  • Blue Cross/Blue Shield
  • Cigna
  • Coresource
  • Healthspring
  • Humana
  • TennCare Select
  • United Healthcare

and several other health insurance providers

If your insurance is not listed, please contact our office.

Privacy Policy

To read more about our Privacy Policy, click here for details.

Contact us

The Children's Clinic of Nashville (615) 297-9541 4322 Harding Pike, Suite 313 Nashville, TN 37205 Click here for more information.