Attention Patient/ Responsible Party:
Insured Party: You are responsible for any referrals or authorization numbers from your Primary Care Physician (PCP). Please ensure your PCP faxes this information to our office prior to your scheduled appoinment or bring the referral/ authorization number with you to your appointment.
If no referral, authorization number, or insurance is available at the time of your appointment, you have the option to pay in full at the time of service. You may also reschedule your appointment to a later date. There will be no exceptions granted. If you elect to pay out-of-pocket please be advised that Panda Pediatrics and Adolescent Care will not submit a claim to your insurance carrier for that particular date of service and all monies will be forfeited and not reimbursed.
Private Pay Patients: You are responsible for full payment of services on the date the services are rendered. If you wish to inquire about payment plans, please contact our Billing Department at 602-283-3606. Payment arrangements need to be made prior to appointment. We accept p Despues de la tercer cita que no asista, tenemos el derecho de sacarle de nuestro practica medica por no seguir instrucciones del medico.ersonal checks imprinted with your name, current address, and phone number. We also require your driver's license and / or credit card information. We accept cash, Visa, Mastercard, Discover, with the exception of American Express, as well.
Please Note: There is a $25.00 charge for missed appointments and a $75.00 charge for missed procedures, if we do not receive notice at least one business day prior to your appointment. Remember you are responsible for keeping your own appointment whether or not our office or hospital contacts you to remind you. After the 3rd missed appointment, we reserve the right to dismiss you from our practice for failing to comply with our physician's medical recommendations.
You are responsible for any outstanding balances not covered by your insurance carrier. Insurance carriers state repeatedly that coverage and /or authorization is not a guarantee of payment.
In the event it becomes necessary to turn your account over to an outside collection agency, you are responsible for all fees associated with recovery, including (but not limited to) collection agency fees, attorney fees, and court fees.
PANDA PEDIATRICS AND ADOLESCENT CARE RESERVES THE RIGHT TO DENY SERVICES TO ANY PERSON WHOM FAILS TO COMPLY WITH THE ABOVE INFORMATION.
I read and agree to the above information. I understand that I am responsible for obtaining my referral/authorization number prior to my appointment and that I am responsible for full payment for services rendered that day. I also understand that I am fully responsible for any outstanding balances not covered by my insurance carrier. Finally, I understand that if my account is referred to an outside collection agency, I will pay all collection agency, attorney, and court fees.