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 do not accept Self Pay patients.
- We offer a flexible payment plan and accept checks, cash or credit cards. You can make payments online or at our office.
- We required a Credit Card on File. Please complete our Credit Card on File Authorization Form and then visit the Front Desk to securely swipe and save your credit card information into our system.
Insurance Plans
- We participate with most major insurance. Open to New Patients: We do not accept Self Pay Patients.
- Aetna (HMO and PPO)
- Aetna Innovation Health
- Anthem
- Anthem BCBS
- Anthem HealthkeepersPlus - NO NEW PATIENTS
- Care First (HMO and PPO)
- Champ VA (Courtesy File)
- Cigna (HMO and PPO)
- Cigna Connect
- First Health/PHCS
- Humana
- Johns Hopkins (US Family Health and EHP)
- MediNcrease
- Multiplan
- Prime Health Services
- Sentara Health Plan
- Student Resources (UHC)
- Tricare
- United Healthcare (HMO and PPO)
- Virginia Health Network
- Web TPA
- We do not accept Self Pay patients
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
Announcement:
RTC Pediatrics is making it easier to get care when we are closed. Through our partnership with Hello Pediatrics we can provide more options for your family.
Starting April 30th, 2025
Hello Pediatrics Hours of Operation: Telehealth Hours
Monday – Friday: 5 PM – Midnight
Saturday & Sunday 12 PM – 10 PM
Holidays: 12 PM – Midnight
Hello Pediatrics Offer the following services:
- Access to telehealth visits with Board Certified Pediatricians in the evening, on weekends, & holidays.
- Continuity of care between Hello Pediatrics & RTC Peds providers.
- Integration of appointment notes into your child’s EHR at RTC Pediatrics
Billing:
Telehealth visits by Hello Pediatrics will be billed to your insurance. Patient balances (copays, deductibles, coinsurance) will be billed and collected by Hello Pediatrics.
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 February 2025 - 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
- Postnatal Depression Scale
- Ages 12 months and older
- Patient Registration
- Ages 18 months and older
- M-CHAT
- Girls ages 13-17 years, Boys ages 14-17 years
- Patient Registration
- Adolescent Questionnaire
- Parent of Adolescent Questionnaire
- Age 18 years
- Patient Registration
- Adolescent Questionnaire
- Parent of Adolescent Questionnaire
- Consent Form for Patients 18+
Release & Consent Forms
- HIPAA Notice of Privacy Practices: Full Notice
- HIPAA Patient Consent Form
- Consent Form for Patients 18+
- RTC Pediatrics Authorization Form for Appointment and Treatment
- RTCP Consent Form for Medical Ear-Piercing
- Telemedicine Consent Form
- Financial Policy
- Release Medical Records from RTCP
- Pre-Op Questionnaire
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.
One of the most important services we can provide our patients is vaccination against life-threatening diseases. Our providers firmly believe in the safety and effectiveness of vaccines to prevent serious illness, as recommended by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC).
Our Policy
- Adherence to Immunizations Guidelines: We adhere to the AAP and CDC immunization guidelines available at: Vaccine Schedule for 0-18 years old.
- Mandatory Vaccinations for School Entry:
- Children must receive all vaccines that are mandated for school entry by the state of Virginia.
- Documentation and Compliance:
- A plan must be documented to ensure that every existing patient is up to date with all vaccines by two, five, twelve, and seventeen years of age. Every new patient over the age of two must have a documented plan to be caught up on all vaccines through nursing visits by their next scheduled well check appointment.
- Non-Compliance Consequences:
- Vaccine refusal will be documented with parental signature on the AAP Vaccine Refusal Form to be scanned in the patient’s medical records.
- Parents refusing to adhere to the AAP recommended vaccine schedule for any reason, except for a documented medical reason, may be discharged from our practice and/or asked to find another healthcare provider who shares their views.
Rationale
We created this vaccine policy to protect children, their families, and our community from deadly, preventable diseases by administering safe and effective vaccines. This Policy ensures that our patients are provided with the best protection against serious illnesses. RTC Pediatrics is dedicated to the health and well-being of all our patients.
RTC Pediatrics
Updated 04/30/2025
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
Walk-In Clinic Guidelines
Monday
8:00 AM – 9:00 AM
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
Walk-In Sick Clinics take place on Monday mornings and Friday mornings from 8:00 AM to 9:00 AM for our established patients only. Established patients are those who have already had at least one office visit with RTC Pediatrics. Walk-In Sick Clinics are for patients with minor illness symptoms lasting less than a week. Patients are seen on a first come, first served basis. Please bring your insurance card and be prepared to pay your copay if applicable.
For sick visit needs 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 appointment.
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
Starting April 30th, 2025 RTC Pediatrics is partnering with Hello Pediatrics to make it easier get care when we are closed.
Hello Pediatrics Hours of Operation:
Telehealth Hours:
Monday – Friday: 5 PM – Midnight
Saturday & Sunday: 12 PM – 10 PM
Holidays: 12 PM – Midnight