Financial Policy/ HIPAA

Please correct the errors described below.

It is important to us that you understand our financial policy, and know that we are always willing to answer any questions you might have.

Our Policy

  • All patients/guardians must sign this financial policy statement.
  • All patients/guardians must provide their personal information on their first appointment prior to seeing the physician.
  • All patients/guardians must have their insurance verified monthly prior to seeing the physician.
  • All the co-pays, deductibles and balances are due at the time of service before you leave the office. All balances must be paid prior to any well visit.
  • Cancellations less than 24 hour notice and/or no shows (which include any late appointments more than 30 minutes late to scheduled appt time are subject to a $25 fee.
  • Premium hour no show and cancellations $40 fee between the hours of 8am-9am.
  • If you write checks for accounts with insufficient funds we will take legal action, and will bill you a $40 service charge for each bad check.

Insurance Coverage

  • You should be fully familiar with your insurance policy including participating hospitals and laboratories, and whether your plan requires referrals to see specialists.
  • Insurance is a contract between you, your employer, and the insurance company. As part of this contract, we are required as providers to collect all co-pays, deductibles, and balances.
  • Not every insurance company will cover all the services that we perform. This office does not always know what different insurance companies will pay. By signing this document, you are agreeing to pay for all coinsurance; deductibles, co-pays and non-covered charges that your insurance company deems are your financial responsibility to us as the providers.
  • If you change insurance companies, it is your responsibility to inform our staff. If you fail to do so and we file the claim with the wrong company, you could be responsible for the entire fee if the claim surpasses the filing deadline with the correct company.
  • If your insurance company does not pay the bill after repeated attempts by this office to file and obtain payment, the unpaid balance will become your responsibility. If you are able to get the insurance to pay, you will be promptly refunded minus the due coinsurance.

On Billed Statements

  • You will be getting statements in the mail.
  • You have two payment options.
    1. Pay the Bill in Full within 30 days of the date posted on your statement.
    2. If you cannot pay the bill, you have 30 days to come to the office and set up a payment plan with the office staff, (first payment being due upon signing the payment agreement).
  • Failure to comply with at least one of these options will result in your account being sent to collections. You will also receive a letter that you have been released from the practice and need to find a new physician. Late balances (greater than 60 days) are subject to a 1.5% monthly interest rate, annual percentage rate of 22%. The guardian assumes all costs of collections, including, but not limited to court costs, interest, and legal fees. In this eventuality the undersigned waives venue jurisdiction
  • And submits to the jurisdiction and venue of the State courts of Broward County.

Authorization of Medical Release

Personal Care Pediatrics is authorized to disclose all or part of the medical record on the above named patient to insurance companies, organizations or agencies responsible for payment of services performed by Personal Care Pediatrics. Also, your insurance company (s), organizations or agencies responsible for payment are authorized to give all medical records to this office. This includes treatment for drug/alcohol abuse, mental health, HIV virus and sexual assault. Although the confidential nature of the information may result in a denial of payment by insurance coverage for services performed in this office.

Verbal Permission:

We may use or disclose your information to family members that are directly involved in your receipt of services with your verbal permission.

Website Privacy

Any personal information you provide us with via our website, including your e-mail address, will never be sold or rented to any third party without your express permission. If you provide us with any personal or contact information in order to receive anything from us, we may collect and store that personal data. We do not automatically collect your personal e-mail address simply because you visit our site. In some instances, we may partner with a third party to provide services such as newsletters, surveys to improve our services, health or company updates, and in such case, we may need to provide your contact information to said third parties. This information, however, will only be provided to these third-party partners specifically for these communications, and the third party will not use your information for any other reason. While we may track the volume of visitors on specific pages of our website and download information from specific pages, these numbers are only used in aggregate and without any personal information. This demographic information may be shared with our partners, but it is not linked to any personal information that can identify you or any visitor to our site.

Our site may contain links to other outside websites. We cannot take responsibility for the privacy policies or practices of these sites and we encourage you to check the privacy practices of all internet sites you visit. While we make every effort to ensure that all the information provided on our website is correct and accurate, we make no warranty, express or implied, as to the accuracy, completeness or timeliness, of the information available on our site. We are not liable to anyone for any loss, claim or damages caused in whole or in part, by any of the information provided on our site. By using our website, you consent to the collection and use of personal information as detailed herein. Any changes to this Privacy Policy will be made public on this site so you will know what information we collect and how we use it.


You will be notified immediately if we receive information that there has been a breach involving your PHI.

I, as a patient or guardian of a patient of Personal Care Pediatrics am agreeing to pay Personal Care Pediatrics for services rendered. I authorize payment directly to Personal Care Pediatrics for benefits that may be due and payable under the insurance coverage for the named patient. If I have Medicare or Medicaid I certify that the information given by me in applying for payment under Title XVIII or XIX of the Social Security Act is correct, and request payment of authorized benefits be made payable on my behalf to Personal Care Pediatrics. I authorize copying or using this application for purposes of processing claims and gaining payment.

I have read and am now aware of the above financial statement and authorization of medical release. I have also been provided with Personal Care Pediatrics’ HIPAA Statement of Privacy

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.

I am the patient, parent, or guardian of the following patients:

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