Uninsured or Underinsured Patients

We believe that every child deserves access to essential healthcare services.

It is the policy of Lafayette Pediatric Clinic to provide essential services regardless of a patient’s ability to pay. We offer discounts based solely on family income and size.

If you think you may qualify for this discount, please complete the application below. Bring the completed forms and all required documentation to your appointment. If you are unable to fill out the form before your appointment, our front desk can provide you with one to fill out at your appointment. Once we receive your application, we will review the information to determine if you or your family members are eligible for the discount.

If approved, the discount will apply to all essential services received at Lafayette Pediatrics Clinic, but not those services performed outside our clinic. Some of the services that are not covered include:

• Reference laboratory testing

• Drug or prescription medications

• X-rays or imaging (including interpretation by a consulting radiologist and other such services)

Additionally, you must update your financial information form and submit new documentation for continued eligibility every 12 months. If you have any questions, please give us a call at (662) 236-3939.