1. Thank you for choosing Newport Children’s Medical Group @ Mission for your child’s health needs. We would like to let you know we are glad to bill your insurance carrier for the service’s you child receives.
2. Please be aware with the great number of insurance policies that cover our many patients. It is impossible for our staff to keep up with all the various insurance carriers benefits related to the services your child may receive.
3. We strongly encourage you to become familiar with your insurance benefits. We will make our best effort to coordinate your benefits regarding physicals, well checks, and out of network referrals. Laboratory and X-ray services. However, you are the subscriber to the benefits and or office cannot accept responsibility for lack of benefit coverage.
4. After hours services is a benefit to both our patients and the community and most insurance carriers honor the charge of $50 dollars Monday-Friday from 5p.m-7p.m., Saturday from open to close, and a charge of $50 on Sundays from open to close, as well as holidays. However, occasionally an insurance carrier does not pay this service. The after hour fee is to maintain professional staff during their special hours (I,e,, weekdays after 5pm and Saturday, Sundays, and holidays). There is also a $40 dollar walk in fee for all patients who come in without an appointment.
5. All insurance plans are billed as a courtesy and we will provide your insurance carrier with all the necessary information for claims processing. We will bill your insurance carrier up to two times per visit. We encourage you to retain the EOB’s (explanation of benefits) your insurance carrier mails you to track the status of your account. If your insurance carrier denies our claim due to the lack of benefits or is slow to pay, you are ultimately responsible for payment of the bill. All services must be paid within 60 days of the service.
6. Payment of office co-pays and any outstanding patient balances are expected at the time of service.
7. In order to provide the maximum physician availability for all our scheduled patients; there is a $50 dollar cancellation fee if our office is not notified 24 hours prior to your appointment. If missed appointments are a recurrent problem; we may have to discharge you from our service due to the inconvenience placed on other patients’ schedules. As a courtesy to you, our office will make a reminder call the day prior toy your appointment.
8. All returned checks will result in a returned check fee of $25 dollars. If the problem persists it will result in having co-pays and co-insurance’s being paid in another form of payment.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.