Thank you for choosing West Side Pediatrics as your child’s healthcare provider. We are committed to providing you the best quality medical care. We look forward to establishing a lasting relationship and partnership with you in caring for your child. As a part of this relationship, we wish to establish our expectation of your financial responsibility.
USUAL AND CUSTOMARY RATES:
We participate with most insurance plans. Your insurance coverage and benefits are a contract between you and your insurance company. Not all insurance policies cover all services. It is your responsibility to check with your insurance company to determine covered benefits. You are responsible for payment regardless of the insurance company’s determination of usual and customary rates. You are responsible for any balance remaining after your insurance carrier has processed the claim.
INSURANCE COLLECTION:
It is your responsibility to ensure that we have the most current copy of your insurance card, demographic and contact information. If your insurance is not verified at time of service, you will be responsible for payment at time of service.
CO-PAYMENTS:
Payment is expected at time of service. Certain services are not covered by your insurance. For any questions regarding services/treatments, we encourage you to contact our Billing Manager and/or your insurance carrier to review costs. Failure to pay at the time of service will result in a $25.00 service fee. As a convenience, we accept all major credit cards, debit cards, cash, and checks.
DEDUCTIBLES AND FEES:
Insurance deductibles are due at the time of service rendered. Failure to produce payment at check-in will incur a $25.00 fee. Patients with high deductible plans will be required to pay $75.00 at time of service for sick visits and consults. If there has been an overpayment, we will issue you a refund check
OUT OF NETWORK/NON-PARTICIPATING INSURANCE CARRIERS:
If your insurance carrier considers us “out of network” or does not participate with us, you are responsible for payment in full at the time of service. We will gladly provide any proof of visit/receipts, etc.
WELL VISITS:
Good health care for infants, children and adolescents begins with the Well-child visit (checkup) and other services that keep children healthy. These are preventative services. There may be times when a child needs a service that is not considered preventative on the same day as a Well-child visit. If a child is not well or if a problem needs to, or is asked to, be addressed during the checkup, the provider will need to provide an additional office visit service (called a sick visit) to care for the child. This is a different service and is required to be billed to your health plan in addition to the preventative services provided on that day. If you have co-payment for office visits or coinsurance or deductible amounts that you must pay before your health plan pays for these services, our office has to charge you these amounts in accordance with the contracts that we have with your health plan.
We value your time and want to make the most of each appointment for your child. This is why we offer the opportunity to address any problem that needs a provider’s care during the well child visits so that only one trip is needed.
DIVORCE DECREES:
In the case of services provided for minors, the individual who initiates services for the child will be responsible for payment. This office is not a party to your divorce decree. We do not bill another individual or estranged spouse for payment. Copayment is due at the time services are rendered. If the divorce decree requires the other parent to pay all or part of the treatment, it is the authorizing parent’s responsibility to collect from the other parent. West Side Pediatrics will not act as a mediator in collecting our payments.
PAST DUE PAYMENTS:
Just as we make every effort to accommodate you when your child is in need of medical care, we expect you will make every effort to pay your bill promptly. If you have a financial hardship, or if you are unable to pay your bill in its entirety, please contact our billing office to discuss payment options. If your account becomes delinquent (past due 60 days) your account will be subject to interest, rebilling fees, and collection costs. Should collection action become necessary, the responsible party agrees to pay collection fees, and all legal fees of collection, with or without suit, including attorney fees and court cost. No balance over $300.00 can be carried on a family account without a scheduled payment plan.
AUTHORIZATION
I authorize West Side Pediatrics to release all requested information concerning my medical treatment to my insurance carrier. I further authorize my insurance company to pay from the proceeds of benefits of any recovery or insurance payments in my case, directly to the provider(s) of this office, for their professional services rendered.
West Side Pediatrics reserves the right to dismiss any patient from the practice who consistently fails to meet this policy or who refuses to sign this agreement.
By signing below, I understand and agree to the terms of this office’s Financial Policy.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application