Thank you for choosing Caring Hands Children’s Clinic as your child’s healthcare provider. We are committed to providing your child with the highest level of care in a warm and loving atmosphere. To be clear and eliminate confusion on payment for services, we have adopted the following financial policies. Please read them carefully and feel free to ask questions if any part is unclear. As always, we are willing to work with you, if there are special financial circumstances.
Payment for Services:
Payment is required at the time services are rendered. Regardless of your insurance coverage, you are ultimately responsible for full and timely payment of all charges incurred at Caring Hands Children’s Clinic. If you fail to make payment in full or prior financial arrangements with our billing manager, any overdue balance on your account may be sent to an outside collection agency which may result in your termination from our practice. You will be responsible for any additional fees charged by the collection agency. If you receive a statement from our office, payment in full is expected at that time. If you cannot pay the entire balance due, please contact our billing manager to set up payment arrangements.
Please note that whoever brings the child in for the visit (i.e. grandmother, aunt, etc.) is responsible for any co-pays, coinsurance and deductible amounts due at the time of service.
We have established payment contracts with several insurance carriers. This means we will file your insurance claims for you and accept their allowable amount as our full charge for those services. The only secondary insurance we file is Blue Cross Blue Shield.
Acknowledgement and Acceptance of Financial Policy:
I agree to the above terms of this financial policy and understand that it may change at any time without written notice. I further understand that whoever brings my child in for visits is authorized to receive financial and medical information on my child and will be responsible for paying any co-pays or deductibles due at time of service. I also agree that if my child is over the age of 18 I will continue to accept financial responsibility until they no longer receive services at The Children’s Clinic. I understand this authorization will remain effective until I provide written revocation.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.