Omaha Childrens Clinic (OCC) Financial Policy

You are required to:

• Present your insurance card at the time of service
• Present a picture ID (driver's license preferred) for verification of identity
• Inform us as soon as possible if your insurance carrier changes and provide us with a copy (front and back) of your new card.
• Pay your co-pay at the time of service. As participating providers with your medical plan our office is required to collect your copayment on the date of service.
• Submit payment and assume responsibility for any and all charges your health insurance company does not pay for. This includes your co-pay, co-insurance, policy deductible, and any and all non-covered services and the outstanding balance after your insurance company has submitted payment to OCC.
• Pay your account balance in full within 30 days of receiving OCC statement of outstanding charges. If your payments are not received and your account is not kept current, your account will be sent to OCC Third Party collection agency. Please note you will be responsible for all collection fees. Provided below is a more detailed description of your financial responsibilities.

After Hours Telephone Calls

We may bill your insurance for non-urgent calls to the on-call physician when the office is closed. Each insurance company has their own policy related to reimbursement for these services, and it is your responsibility to understand your company's policy, and any fees you may be directly responsible for. This fee will not apply to calls related to follow up questions from office visits earlier in the day, to calls that lead to an emergency visit, or to calls that lead to an office visit to OCC the following day. Daytime phone calls will continue to be free of charge, and parents are encouraged to look to our website www.omahachildrensclinic.com for answers to their questions when the office is closed.

Responsibility for Payment

Even though you have health insurance, you as the guarantor are responsible for payment of all services provided by OCC. OCC will bill your insurance company for all services rendered, with the information you have provided us. If your insurance information has changed, please notify us immediately so we may bill the correct insurance carrier.

Co-Payment

Your health insurance policy may state that you must pay a co-payment for physician visits. This payment is due the day services are rendered to your child/children. OCC has a contractual agreement with the health insurance carriers to collect all co-pays on the date the services are rendered. OCC accepts cash, checks, Visa and MasterCard.

Remaining Balance

After Your Insurance Company has Paid OCC will submit a claim to your primary health insurance company for services provided. Once your insurance company has processed your claim, OCC will post any payment it receives to your account. If there is a remaining balance, the balance will be your responsibility. This balance may include your deductible, coinsurance and any and all non-covered charges. Payment for this balance is due within 30days of you receiving our statement of outstanding charges. Any balance due after 59 days will be subject to a 1.5% finance charge. This charge will be assessed monthly until the balance on the account has been satisfied.

Divorced Parents

OCC will not get involved in custodial, separation or financial disputes involving or relating to divorced parents for a minor child(ren) to whom we provide services.. The parent who signs the financial policy and registration form of the minor child(ren) will be the responsible party for payments of services rendered.

Credit Card Information

OCC accepts MasterCard and Visa

Check Returned for Insufficient Funds

If a check is returned to OCC for Non-Sufficient Funds, a $35.00 fee will be assessed & collected.

Collection Accounts

Our office will make every effort to communicate with you about your account and will present reasonable options for payment. In the event a bill goes unpaid without contacting our Billing Dept. to discuss payment options, the account will be turned over to collections. If your account is sent to our collection agency a collection charge of 35% of the amount due will be added to the balance of your account.

Failure to Pay

Outstanding Balance If an account is not paid in full within the stated period of time of receiving OCC’s Remaining Balance Invoice, OCC will start the process of turning your account over to a third party collection agency for payment. You will be responsible for all associated collection fees imposed on OCC by the third party agency.

Request for Medical Records See Medical Records Release Form

• OCC may charge up to .50 per page for copies of records that are requested for personal use.
• Record transfer requests will be completed and sent to a provider at no charge to ensure continuity of care within 30 days of the initial request.
• When requesting copies of immunization records, please provide a mailing address and/or fax number when requesting. We will process your request within one week if the record does not have to be retrieved from storage. Requests for records that are in storage may take up to 2 weeks to process.

No-Show for Scheduled Appointments: A charge of $35.00 may be billed for failure to cancel an appointment in advance. We recognize that emergencies occur. Please make every effort to contact us if you need to change your appointment.

I have read the above financial policy for Omaha Childrens Clinic and I agree to the terms listed above.

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.