INSURANCE PLANS/COVERAGE: I understand it is my responsibility to confirm with my insurance company that the provider is currently under contract with my plan or be willing to be seen under “out of network” benefits. I further acknowledge that West Side Pediatrics is not responsible to know what services my insurance covers.
Well and Sick Visits: I acknowledge that I have read and understand the policy on Well Visits.
FINANCIAL COMMITMENT: I agree to be responsible for all copays, deductibles and non-covered services determined by my insurance plan at the time of my visit. I understand that if someone other than me is bringing my child to West Side Pediatrics, they will be responsible to pay for copays and any past due balance. 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. 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.
HIGH DEDUCTIBLE INSURANCE PLANS: I am aware that I will be asked to pay $75.00 at time of service for sick visits and consults. This amount will be applied to your balance and billed to your insurance plan. You will be billed for the balance of your visit once your insurance has determined benefits.
DEMOGRAPHIC VERIFICATION: I am aware that I will be asked to verify insurance and demographic information so records remain current.
NO INSURANCE AT THE TIME OF SERVICE: If insurance benefits cannot be determined, I understand that payment is required in full at the time of service.
PAYMENTS: I commit to promptly pay all amounts that have been determined by my health insurance to be patient responsibility upon receipt of my statement.
SERVICE FEES: I understand my account will be charged $25 for NSF/Returned checks.
LATE ARRIVALS: I have been made aware that if I arrive more than 15 minutes past my scheduled appointment time, the practice may have to reschedule my appointment.
NO SHOWS-WELL CHILD CHECKS AND CONSULTS: I commit to give West Side Pediatrics at least 24 hours’ notice if I am unable to keep my scheduled appointment. I understand if I miss 3 appointments without notifying the practice in a 24-month period, the practice will no longer be able to continue providing pediatric healthcare services and I understand I will be dismissed from the practice. (Note: this is per family, not per child)
NO SHOWS-SICK VISITS: I commit to give West Side Pediatrics at least 2 hours’ notice if I am unable to keep my scheduled sick appointment. I understand if I miss 3 appointments without notifying the practice in a 24-month period, the practice will no longer be able to continue providing pediatric healthcare services and I understand I will be dismissed from the practice. (Note: this is per family, not per child)
I have read, understood and agree to the above financial and office policy. I understand that Non-compliance with this policy may result in a dismissal from West Side Pediatrics.
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