Financial Agreement

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Pediatricians Inc., is committed to serving our patients with professionalism, care and concern. We expect the same commitment from our patients. This commitment includes card at every appointment and making your copay and deductible payments at the time of your visit.

Acceptance of Insurance

Your insurance policy is a contract between YOU and your insurance company. We cannot bill your insurance company unless you give us your insurance information.

Our office cannot tell you in advance whether charges may be covered by your insurance plan. It is your responsibility to know your own insurance benefits. Please be familiar with your own plan, including types of coverage and any restrictions on location of care, laboratory, and referral providers.

We run insurance eligibility prior to every visit. However, ensuring your insurance is eligible, active and listed with the corrected primary care provider (PCP) in our office is your responsibility.

If you have commercial insurance that we do not accept, or your commercial insurance is inactive, you will be considered a self-pay patient, and full payment is expected at the time of service. Alternately, you may choose to reschedule to a later date when insurance has been corrected.

If you have a Medicaid insurance plan, please be advised that we only accept the PCC plan as the primary insurance plan. You MUST be listed on this plan AND have one of your providers listed as your primary care provider (PCP) in order to be seen.

We understand it takes time to obtain accurate health insurance information for a newborn. However, if this is not listed correctly by the time your child is 4 weeks old, we retain the right to reschedule well visits to a date when the insurance has become active. We will always provide vaccines to a child regardless of ability to pay.

Responsibility for the Bill

It is the expectation that all patients/guarantors receiving services are financially responsible for the timely payment of all charges incurred. While the practice will file verified insurance for payment of the bill(s) as a courtesy to the patient, the patient/guarantor is ultimately responsible for payment and agrees to pay the accounts(s) in accordance with the regular rates and terms of practice in effect at the time of the appointment.

Point of Service Collections

Payment for service is due at the time service is rendered, and non-emergency services may be deferred until the necessary payment arrangements have been made. Payment will be accepted in cash, check, MasterCard, Visa, or American Express. Patients unable to comply with the point of service payment policy will be referred to our billing department for necessary arrangements.

Patient Responsibility

All patient account balances are due within 30 days of insurance payment, unless other satisfactory arrangements have been made with the practice. Not all services are covered by all insurance companies. It should be understood that, by accepting the service(s), the patient/guarantor is responsible for payment regardless of whether the insurance covers the service. According to your insurance policy, you are contractually obligated to pay any copay due at the time of service.

Outstanding Bills

The practice reserves the right to request deposits or payment in full for any outstanding balances plus the patient's share of the bill for the new service(s) to be performed.

Payment Arrangements

The practice will make a reasonable effort to assist patients/guarantors in meeting their financial obligations. If unusual circumstances make it impossible for you to meet the terms of this financial policy, please discuss your account with our billing office to arrange a payment plan. This will avoid misunderstandings and enable you to keep your account in good standing.

Missed Appointments

If you need to miss a scheduled appointment, please let us know as soon as you can. After two missed appointments you will incur at $50/charge. After three missed appointments you will be responsible for the entire cost of the visit.

Patient Records

Copies of medical records are available to the patient, parent or legally appointed guardian after we receive a signed release. There will be a $20/charge per medical record. Please allow 10 business days for completion of these requests.

Release of Information

By signing this release of information, I recognize and I have received and understood the aforementioned information and authorize Pediatricians Inc. to furnish information as necessary to insurance carriers and/or third party payers.

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