Office Procedure and Financial Policy

(Birth through 17)

Please correct the errors described below.

Our goal at Glendale Pediatrics is to provide the best possible medical care and to develop and maintain a relationship with both you and your child that will grow and strengthen over the years. Along with our medical relationship, we will be establishing a financial relationship. In order to successfully maintain this relationship, we want you to have a clear understanding of our financial policy. We ask that you read, understand and sign this policy statement prior to any treatment.

Insurance Verification

In order for us to ensure that our office is billing correctly, we require the following at every office visit:

  • Proof of active medical coverage ( i.e. insurance card:).
  • Review of patient demographic information (Note: full demographic information update is required at the first visit of each calendar year.)

If no current proof of active medical insurance coverage is provided at time of visit, payment for services will be required.

Although our medical providers may order necessary testing or referrals to other facilities or providers, ultimately parents, custodians or guarantors are responsible to verify the following information with their insurance carrier prior to making any appointment for the patient:

  • Confirm our providers participate in your child’s medical insurance plan
  • Understand your child’s medical insurance benefits and coverage
  • To which facilities your child can go to have laboratory work
  • To which facilities your child can go to have X-rays, CT Scans or MRIs

A medical insurance carrier can have additional requirements, and parents, custodians and guarantors are responsible for continually understanding their insurance benefits. This is important as Glendale Pediatrics cannot be financially responsible for services patients receive at noncontracted facilities.

As a courtesy to our insured patients, we will bill both primary and secondary medical insurance.

Co-payments are due at the time of service.

Payment for Services Policy

Please read our attached Payment for Services Policy and complete and sign the annual Credit Card Authorization form and return to our front office staff before leaving the office today.

Cancellation Policy

A specific time is reserved for your child when you schedule an appointment. If you cannot keep your child’s scheduled appointment, please give us at least 24 hours’ notice so that we may reschedule the appointment and offer the reserved time to another patient. It is our policy to charge $75 for appointments that have been scheduled in advance and are cancelled/missed with less than 24 hours’ notice. Please be aware that this applies to same day appointments as well.

Unscheduled Appointments

Appointments requested in the office without prior arrangement will be made according to our discretion with consideration given to other patients’ scheduled appointments. Any unscheduled patient who requests that one of our physicians work them into their schedule will be charged a work-in fee of $50. This fee is not covered by insurance and is due at the time of service.

Additional Health Issues Addressed During Preventative Care Appointments.

Preventive Care is an important part of your child’s good health. We recommend and follow the schedule established by the American Academy of Pediatrics. If, during a well visit, your child is sick or has an issue that is not related to the normal growth and development of your child, and he/she needs treatment and/or medical attention or guidance for your concerns, your provider may bill the insurance company for both services. While Preventive Care is covered 100% by most insurance companies, additional issues addressed during a preventive care visit must be billed separately, at which time your insurance benefits might require a co-pay, co-insurance and/or your deductible may apply.

Please note that medical questions regarding an unscheduled sibling will be billed as an office exam.

Saturday Appointments

We offer Saturday morning appointments for urgent visits. While we are happy to offer this appointment-only service, please be aware that there is an additional $50 fee for weekend appointments.

Telephone/Portal Consultations

There will be a consultation charge for most telephone calls and communication through the portal with the doctor to discuss a patient’s health problem(s). We will be glad to bill the patient’s medical insurance company; however, if these charges are not covered under the health plan, parents, custodians and guarantors will be responsible for the payment.

Guardian Requirements

Children under 18 years of age must be accompanied by a legal guardian to all visits at our office. If someone other than a legal guardian will be bringing your child to an appointment, we must have a designee authorization form signed by a legal guardian in your child’s medical chart authorizing this individual to act on behalf of the child’s guardian in order to treat your child. Whoever brings the child into the office is responsible for co-payments and for having a current insurance card at the time of service. If your child arrives without a legal guardian and we have no signed form on file, it will be necessary to re-schedule your child’s appointment. IMPORTANT NOTE - a parent or a legal guardian must accompany a child to their very first visit to Glendale Pediatrics.

Patients Ages 18-23

We accept new patients through a patient’s 18th birthday. We are available to see established patients through their 23rd birthday. Patients who are between 18 and 23 years of age have a right to privacy which is covered by HIPAA laws. That means that we cannot release any information to parents or family members without a signed release by the patient.

Completion of Forms and Request for Medical Records

If you have letters or forms for our doctors to complete (school, sports, etc.), please be aware that there is an administration fee per form for turnaround in 5 – 7 business days. If forms are needed sooner, there will be an additional charge. There is also a fee for duplication of medical records per patient if records are to be picked up. An additional fee will be charged if the chart is exceptionally large, if the charge needs retrieved from storage, or if a request is made for the records to be mailed. Please be advised that we do not fax or email medical records.

Divorced or Separated Parents

The parent bringing the child into the office will be required to make any co-payment required for the visit that day. Unless Glendale Pediatrics has a letter in writing signed by both parents, both parents are deemed to be financially responsible for their child’s account balance. Glendale Pediatrics has a formal Divorce Policy which will apply to all of our divorced or separated parents. Please ask our front staff to provide you with a copy if you require additional information.

Maintaining a Respectful Environment

The doctors and staff strive to treat our patients with courtesy and respect. It is also important that we insure that our staff and our billing service is treated with respect from our patients, parents, custodians and guarantors, as well. We feel very strongly that our staff should be able to work in an environment free from verbal and physical abuse. Angry outbursts against our office or billing staff, either in person or on the telephone, will not be tolerated and will result in a patient’s discharge from the practice.


Financial requirement for all of our patients.

In order to continue our current contracts with insurance carriers, it has become necessary for us to establish limits on the length of time we can carry outstanding balances for our patients.

Therefore, prior credit card payment authorization for missed co-payments, fees for cash patients not paid at the time of service, work-in fees and unpaid balances beyond 60 days from date of service is now expected of all patients.

At check-in, your credit card information will be obtained and stored securely. In the event, that your authorized card changes or is declined, you agree to immediately notify Glendale Pediatrics and provide us with a new, valid credit card which will be used to charge any payments as described above.

A $35 fee will be accessed if your credit card payment is declined for any reason. Please make sure that the card information you give us is accurate and that your credit card on file remains valid at all times. If your credit card on file declines a second time within a calendar year, your delinquent account balance will be forwarded to a collection agency and it will be necessary for us to discharge your child or children from our practice.

Cash patients will need to pay in full at the time of service. For your convenience we accept cash, checks, MasterCard ,Visa, American Express and Discovery Card. There is a $35 charge for all returned checks.

We do realize that temporary financial problems may affect timely payment of your account. If such problems do arise, please contact our billing service immediately after receiving your first statement for assistance in the management of your account. Payment plans are available for hardship cases with prior credit approval. Our billing service can be reached Monday through Thursday at (626) 332-0556.

Please complete and sign the attached Credit Card Authorization form and return it to the Receptionist today.

Thank you.

(Birth through 17)

I have read and understand the Office Procedure & Financial Policy and Payment for Services Policy for Glendale Pediatrics.

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