Well Exams, "Sick" Visits and your Insurance

We are very pleased that you have come in today for your child’s wellness exam. This examination provides an opportunity for your doctor to obtain information about your child’s health for future use. It also provides an opportunity to review recommended screening tests according to your child’s age, teach good health practices, and identify health problems in the early stages.

Please read the following so you are informed of charges for today’s visit for which you may be responsible.

Well Baby/Well Child Exam:
includes vital signs, height/weight measurements, assessment of development, questions about diet, a physical exam of the child’s body, routine vaccinations and assessments of vision and hearing as needed, and age-specific education regarding your child.

• Please be aware that the review of your chronic medical problems or conditions including prescription refills as well as any new medical complaints are not part of a “Well” exam and therefore require specific coding and are billed separately. We know your time is valuable and your doctor will do his/her best to address your problems or conditions at today’s visit as a courtesy but your insurance may not cover it at 100%.
• You may wish to schedule a separate office visit for the other conditions if you are unsure of your insurance coverage.

Please inform your doctor if you wish to schedule a separate office visit to address these items.

Please also note that some insurance companies choose not to cover services that your doctor may recommend today to keep you healthy, including blood tests. Your doctor orders tests based on your specific health needs and not what your insurance covers. Some charges may be your responsibility.

I have read and understand the above. I agree to be responsible for any charges that my insurance company does not cover.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.