Welcome and thank you for choosing our practice for your medical care. We are committed to providing you with the highest quality medical care possible in a cost-effective manner. Our professional fees have been determined through careful consideration in addition to being reasonable and customary within our geographical area. We are pleased to discuss with you any questions you may have concerning a bill. As a courtesy to our patients, we accept cash, personal check, money orders, and all major credit cards.
In order to achieve our goal of providing you with the best care possible, we need your assistance and understanding of our financial policy:
Copays are due at the time service is rendered. The person accompanying the child for the visit is responsible to make the copay.
Forms needed to be filled out by the physician will result in either $5 or $10 charge to be paid when the form is submitted to the office for completion. An updated well visit or comprehensive visit will necessary in order for certain forms to be completed. Please allow up to two weeks for completion. (Please talk to the front desk for any further details.)
If a situation arises where you can not make the full payment within 30 days of receiving our bill, we may be able to assist you with payment, through utilizing a payment plan. Our office will discuss a payment plan with you, but we need to be contacted as soon as possible following the first bill sent. Our billing department’s phone number is 732-846-4966.
By signing this document, I have fully read and understood the financial policy of University Pediatric Associates. I hereby consent to allow the practice to reach me via:
I will cooperate with the billing department of University Pediatric Associates to ensure payment for services rendered to the child(ren), and understand the terms of this financial policy. I understand that I will be responsible for any cost(s) associated with the collection of my account if I default on this agreement. In the event that the patient is a minor, I am the parent and/pr legal guardian of said patent and agree that I am responsible for payment for all services rendered to the patient herein.
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