Office Procedure and Financial Policy

(Over 18 years of age)

Please correct the errors described below.

The goal of the doctors and staff of Glendale Pediatrics is to provide the best possible medical care for you and to develop and maintain a relationship with you that will 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: Completion or updating of full demographic information form is required at your 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 order necessary testing or referrals to other facilities or providers, ultimately patients are responsible to verify information with their insurance carrier prior to making any appointment:

  • Confirm our providers participate on their medical insurance plan
  • Understanding your medical insurance benefits and coverage
  • Where you can go to have laboratory work
  • Where you can go to have X-rays, CT Scans or MRIs

A medical insurance carrier can have additional requirements; patients are responsible for continually understanding their insurance benefits. This is important as Glendale Pediatrics cannot be financially responsible for services patients receive at non-contracted 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, complete, 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 you when you schedule an appointment. If you cannot keep your 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 $50.00. This fee is not covered by insurance and is due at the time of service.

Additional Health Issues Addressed During Preventative Care Appointments.

Preventative Care is an important part of your good health. We recommend and follow the schedule established by the American Academy of Pediatrics. If during a well visit you are sick or have an issue that is not related to the normal growth and development and that needs treatment and/or medical attention or guidance for your concerns, your provider may bill the insurance company for both services. While Preventative Care is covered 100% by most insurance companies, additional issues addressed during a preventative 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.

Saturday Appointments

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

Telephone 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, you will be responsible for the payment.

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 or if you request that the records be mailed. Please be advised that we do not fax or email medical records.

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.

Working with multiple insurance companies has become increasingly challenging for medical practices. More and more delayed payments from carriers and patients have placed a severe operational burden on private pediatric practices. There is an increasing trend for private practices to terminate their affiliation with insurance carriers and become concierge private practices.

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 pays, 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 security. In the event, that my authorized card changes or is denied, I agree to immediately notify Glendale Pediatrics and provide them with a new, valid credit card which I will allow them to charge over the telephone for my payments due as described above.

Insurance patients are required by your health plan to pay your co-payment at the time of service. Any co-pay or triaged walk-in fee not paid at the time of service will be billed to your credit card on file on the same date of your child’s service. We will also bill to the credit card on file all unpaid balances remaining on your account 60 days from the date of service.

A $35.00 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 $35.00 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.

(18 and Over)

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

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