Policy Agreement Form

PHOENIX PEDIATRICS, LTD. POLICIES AGREEMENT
By signing this form you agree to abide by the policies of Phoenix Pediatrics, Ltd. The undersigned agrees to pay in full any and all accounts for their dependents over 60 days old. For any balance over 60 days, we will require you to speak with a billing representative prior to scheduling any appointments. If the account is not paid in full and prior arrangements have not been made, the account(s) may be referred to collections. In the rare case of an account referred to collections, you will be responsible for all attorney’s fees and collection agency expenses.

PAYMENT IN FULL/INSURANCE SUBMISSIONS
I authorize Phoenix Pediatrics to release any medical or other information to the insurance carrier which may be necessary to process claims. Payment in full is required at the time of service for all past due balances, deductible amounts that have not been met, non-insured patients, and any coverage that could not be verified at the time of service. You are responsible for payment of all charges incurred. All balances not paid by the insurance carrier by 60 days of the date of service will be your responsibility. We will be happy to reimburse you for any payments made by you after your insurance company has paid in full; however, in the event, an insurance payment is made to the policyholder you are responsible to submit payment in full to this office immediately.

RETURN CHECKS
Checks that are returned to our office for any reason are subject to a $25 service charge and referral to the Maricopa County Attorney’s Office Check Enforcement Program. The service charge and the amount of the check must be paid in full within three business days. Please arrange to pay by cash or credit card for future visits as we will no longer accept checks as payment on your account.

DIVORCE/CUSTODY
The parent and/or legal guardian who brings the child in for medical services will be responsible for any payment due at the time of services. We do not bill third parties regardless of what the decree or custody documents indicate. Please provide custodial documentation for the release of medical information.

NO-SHOW/CANCELLED APPOINTMENTS
All appointments must be canceled or rescheduled one hour prior to the scheduled appointment time. No-show appointments will be subject to the following charges: 1*t encounter fee will be waived, the 2™ encounters will result in a $25 fee, the 3" encounter will result in the family being discharged from the practice and your insurance company will be notified.

HIPAA NOTIFICIATION
I have been informed about, and given the opportunity to obtain a copy of Phoenix Pediatrics’ Notice of Privacy Practices pertaining to the Health Insurance Portability And Accountability Act (HIPAA).

I HAVE READ AND UNDERSTAND THE INFORMATION ON THIS FORM. I CERTIFY THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.