Policies & Forms
Learn about the policies that help us provide you with the very best of care.
Billing & Insurance
RTCP is dedicated to providing you with the highest quality, cost effective medical care. Our billing team is available to answer any questions you may have regarding your insurance coverage or billing issues. Contact them at (703) 435-0726 or billing@rtcpeds.com.
Payment Policies
- We will gladly file claims with your participating insurance company, however you are expected to pay all co-pays or co-insurance prior to your child being seen.
- We offer a flexible payment plan and accept checks, cash or credit cards. You can make payments online or at our office.
- Please ask a front desk team member if you would like to keep a credit card on file. Read our FAQ for more information about this payment method.
- For self-pay patients, we require payment in full at the time of the visit.
Patient Balance Late Fees
- There is a $15 additional charge for copays that are not paid within one week of your child’s visit.
- Accounts with a balance over 30 days will be assessed a 1.5% late charge per month on the unpaid monthly patient balance.
Excluded Insurance Plans
- We participate with most major insurance. However, we do NOT participate with the plans listed below. This is subject to change. Please contact your insurance company or call us with any questions.
- Administrative Concepts, Inc.
- Aetna Medicaid
- Anthem HealthkeepersPlus - NO NEW PATIENTS
- CareFirst Blue Choice HMO
- Cigna HMO
- CIGNA Medicaid
- Compass Rose
- Humana
- Kaiser
- PHCS
- Tricare Prime/Champus/ChampVA
- United Health Care CCC (Medicaid)
- United Health Care PDSM
- Virginia Medicaid (The Blue/White Card)
- We do not have a contract with any of the "Exchange Products" (Insurances that are purchased on-line for Self-Employed or Unemployed)
Patient Forms & Assessments
Registration forms for new patients, release and consent forms, and developmental assessment tools
New Patient Forms
- Please arrive 15 minutes before your scheduled appointment to complete any outstanding paperwork, provide your Insurance Card for scanning and your Credit Card information. If your child is older than 4 months, you may call the office to schedule a new patient well check. Appointment availability may vary based on demand. Currently we are scheduling new patients over 4 months old in January 2025. If you are interested in establishing care with RTC Pediatrics, please complete the age-appropriate intake forms below. You will be contacted within 5 business days to schedule the next available new patient well visit appointment. For new patients up to 4 months old, we have appointments reserved each week for new baby well visits. If you have a baby 0-4 months old, call our office to get scheduled right away.
- Patient Registration - One form for entire family
- Credit Card on File REQUIRED - One form for entire family
- Newborn Questionnaire - One per patient under 12 months old
- Pediatric Questionnaire - One per patient over 12 months old
Existing Well Patient Forms
- Please arrive 15 minutes before your scheduled appointment to complete any outstanding paperwork, provide your insurance card for scanning and your Credit Card information.
- Ages 2-6 months
- Patient Registration Form
- Postnatal Depression Scale
- Ages 12 months and older
- Patient Registration Form
- Ages 18 months and older
- M-CHAT
- Girls ages 13-17 years, Boys ages 14-17 years
- Patient Registration Form
- Adolescent Questionnaire
- Parent of Adolescent Questionnaire
- Age 18 years
- Patient Registration Form
- Adolescent Questionnaire
- Parent of Adolescent Questionnaire
- Consent Form for Patients 18+
Release & Consent Forms
Developmental/Behavioral
- ADHD Vanderbilt Assessment
- Vanderbilt (Parent)
- Vanderbilt (Teacher)
- Follow-Up Vanderbilt (Parent)
- Follow-Up Vanderbilt (Teacher)
- Med Trial
- Med Trial Directions for Parents and Teachers
- Med Trial-Parent
- Med Trial-Teacher
- Screen for Child Anxiety Related Disorders
- SCARED (Child)
- SCARED (Parent)
- Mood & Feelings Questionnaire
- MFQ (Child)
- MFQ (Parent)
School Forms
School, camp, sports, daycare, and medication administration forms
Financial Policy for School Forms
We are going Green! Starting June 15, 2024, after a completed Well Check, Virginia School Forms will be shared to the patient portal. If a printed copy is required, there is a fee of $20 per printed form.
Please bring any other forms that require a provider’s signature with you to your child’s yearly physical exam, so we can complete them at no additional cost to you. Please ensure that you complete all components of that form prior to your child’s arrival at our office.
If the necessary forms are not presented at the time of the yearly physical exam, but rather brought in or mailed to our office for completion after that visit, you will be charged a $20 administrative fee for each form.
If you need the form(s) in less than 72 hours, the charge is $20 for each form PLUS an extra $25 rush fee for the form(s).
For example, if a family is requesting 3 forms for 3 children with a rush request, the total charge is $60+$25 = $80 Total for forms. Fees will be due prior to pickup of the completed forms.
If you are requesting that our office mail your child’s form back, you will need to send payment along with that form. Please be aware that these fees are not covered by your medical insurance policy.
School Forms
- We are going Green! Starting June 15, 2024, after a completed Well Check, Virginia School Forms will be shared to the patient portal. If a printed copy is required, there is a fee of $20 per printed form.
- VA School Entrance Health Form
- Virginia Sports Form QuestionnaireThis Form must be filled out on May 1st or later.
- TB ScreeningPlease fill out and hit the Submit button.
Vaccines Save Lives
At RTC Pediatrics, we believe that all children should receive the recommended vaccines according to the schedule provided by the American Academy of Pediatrics (AAP) and the CDC. Vaccines are safe and effective in preventing diseases and their subsequent health complications.
For the safety of all our patients, families and staff, we require all of our patients to receive all recommended vaccines by age 2. We are happy to discuss any concerns about vaccines at your child’s next visit.
RTC Pediatrics
1830 Town Center Dr.
Suite 205
Reston, VA 20190
Map & Directions »
Phone
(703) 435-3636
Fax
(703) 435-9145
Billing Team
(703) 435-0726
billing@rtcpeds.com
Office Hours
Monday - Friday
8:00 am - 6:00 pm
Telephone advice available 8am - 1pm, 2pm - 5pm
Saturday
9:00 am - 12:00 pm
By appointment only
We are required to report visits outside of normal business hours to your insurance provider. Appointments scheduled before 8am, after 5pm, on Saturdays and on Federal holidays will incur an additional fee, which may be applied to your copay, coinsurance, or annual deductible.
We are closed for Christmas Day, New Years Day, Memorial Day, Independence Day, Labor Day, and Thanksgiving Day.
- We require an appointment for your child to be seen.
- Telehealth sick visits are available. Call us to schedule.
Walk-In Sick Clinic
Monday
8:00 am - 9:00 am
Tuesday/Wednesday/Thursday
NO WALK-IN CLINICS - BY APPOINTMENT ONLY
Friday
8:00 am - 9:00 am
Walk-In Sick Clinics take place on Monday mornings and Friday mornings from 8:00 AM to 9:00 AM for our established patients. At any other hours of the day or days of the week, please call our office at 703-435-3636 and choose option 3 to speak with one of our nurses to schedule a sick visit.
Monday
8:00 AM – 9:00 PM
Tuesday/Wednesday/Thursday
NO WALK-IN CLINICS. All sick visits are BY APPOINTMENT ONLY on Tuesdays, Wednesdays, and Thursdays.
Friday
8:00 am – 9:00 am
Our Walk-In Sick Clinic is for established patients with minor illness symptoms lasting less than a week. Established patients are those who have already had at least one office visit here. Patients are seen on a first come, first served basis.
Please bring your insurance card and be prepared to pay your copay, if applicable.
After-Hours Care
If your child’s illness or injury is life threatening, call 911.
Save time and call us before you take a trip to urgent care. When the office is closed, you may choose to be connected to our after-hours answering service. If needed, they can connect you to the physician on call. The fee to speak to someone after hours is $25/call. This service is not billed to your insurance.
Poison Control Hotline
(800) 222-1222