Financial Responsibility Agreement

Please correct the errors described below.

I understand and agree that I will be financially responsible for the patient services provided by Mt. Airy Pediatrics, PC according to the policies stated in this Financial Responsibility Agreement.


I acknowledge that I am responsible to ensure that the patient information provided to the office is true and correct. I will notify the office about any significant future revisions to the patient information furnished. In order to allow the staff to process and changes or updates to my information, I will plan to arrive at least 15 minutes early for my scheduled appointment. I agree to make my insurance card available to the staff at every visit, as well as any pertinent information for the insured parent/guardian (i.e. date of birth, social security number, full mailing address).


I understand that my insurance plan is a contract between said insurance company and myself. It is my responsibility to follow up with them if I have any questions about rejected claims. Some small private health insurance companies will pay for services on a fee for service basis however it is my responsibility to check with that individual plan for specific reimbursement rules. If my insurer has not paid the office within 90 days after a claim is submitted, Mt. Airy Pediatrics, may then require me to pay for the patient services in full.

If you belong to a health maintenance organization (HMO) that requires you to choose a PCP (Primary Care Physician)-I will make sure that the office name, phone number and/or provider number are on any member identification card prior to any appointments here.

If we do not participate with your insurance carrier: Mt. Airy Pediatrics will attempt to bill once if I provide them with the following information- Name and mailing address of your insurance carrier, policy number, group number, policy holders' full name, policy holders' date of birth and social security number. The office will bill my insurance company only once for each date of service. It will remain my responsibility to ensure that the claim has been paid in full within 30 days of the service date.

If you have no insurance coverage: Payment must be made at the time of the service unless an acceptable payment plan has been agreed upon with our staff prior to the services rendered.


All co-pays, co-insurances and any account balances must be paid when I arrive for a scheduled appointment. The office’s contract with requires the front desk staff to collect co-pays at every visit. A $10 surcharge will be assessed to your account if you do not pay your co-pay at the time of the service. We reserve the right to refer your account to our collection agency if an account balance goes unpaid for longer than 90 days. We may also find it necessary to dismiss patients from our practice if we are unable to resolve an unpaid balance issue.


I agree to resolve any account balances resulting from administrative or processing fees in a timely manner.

Surcharge - If I fail to make to make a copayment on the date of service, I can be assessed a $25 fee.

Returned Checks - If my check is returned by the bank, I will be assessed a processing charge of $35

Cancelled Appointments - If an appointment is cancelled with less than 24 hours notice, I can be assessed a cancellation charge of $20.


All copayments, co-insurances, previous account balances and payments for services must be made at the time of the service unless an acceptable payment plan has been agreed upon with our practice administrator or staff prior to the services rendered. The office will not otherwise approve any deferred payment schedule.


If my account is more than 90 days in arrears, it will be referred to a collection agency and that the office may then deny subsequent patient treatment if my account balance remains unpaid.

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