PAYMENT FOR SERVICES POLICY
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.