Forms & Policies

Dr. Luis R. Rodriguez and the staff of My Children's Doctor, P.A. would like to thank you for selecting our office as your child's health care provider. We understand the importance of this decision and look forward to caring for your child's future today.


In order to expedite your visit to our office, and decrease the amount of time spent in the waiting room, we have provided our New Patient Forms online for your convenience. You may either: 1) print out these forms, bring them with you at the time of your of appointment and inform the receptionist, or 2) fill out your information on the day of your appointment using a Phreesia pad.

Our practice uses the Phreesia pad for self-service check-in. Click on the image to see the benefits of using the Phreesia pad!


Additionally, please make sure to bring the child's insurance card, a copy of the child's shots record, and a copy of your driver's license when coming to your appointment. These items must be presented in order to complete the new patient packet and for your child to be seen.


Download Patient Forms

Print New Patient Record (English)


Imprimir Archivo De Paciente Neuvo (Spanish)


Office Policies

Notice of Privacy Practices


Office Policies

Insurance & Billing

As is standard practice, payment is expected at time of service unless previous arrangements have been made with our office. Our office accepts cash, personal check (with proper ID), MasterCard or Visa payments, and most major insurance companies.

We are providers for many insurance companies; however, it is your responsibility to understand whether your insurance has limits on the doctors you can see, or the services you can receive. If your insurance policy requires you to meet a deductible, you will be expected to pay at the time of service until deductible has been met, even though we are assisting you in filing your claims. Information obtained from your insurance company is not a guarantee of payment. Please remember that insurance contracts are made between the patient and the insurance company. Insurance companies frequently set fees that are below customary charges. Payment of the bill is therefore your responsibility.

Give us a copy of your insurance card, so that we may check your insurance benefits before your visit.  If the physician or the nurse practitioner has recommended that your child be evaluated by a sub-specialist or have x rays or tests done, and you are on a managed care insurance plan, please contact our office to obtain the authorization from your insurance company for the recommended service. 

Some of the Accepted Insurance Plans:

bullet Aetna
bullet Blue Cross & Blue Shield
bulletChildren Medical Services (CMS)
bullet Cigna
bulletGolden Rule
bullet Humana
bullet Humana Military (Tricare)
bullet Medicaid
bulletPrestige Health
bullet Staywell (Medicaid HMO)
bullet United Health Care

Please contact our billing office or call your insurance carrier should you have questions.


My Children's Doctor, PA • 2484 Caring Way Suite F Port Charlotte, FL 33952 • Office: (941) 625-1999 • Fax: (941) 625-4600

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MyChidrensDoctor.com™ and its affiliated sites are owned, operated, maintained and hosted by Luis Rodriguez.