Financial Policy

• Insurance card: We request a valid copy of your insurance card yearly to ensure claims are being billed to your insurance in a timely manner.
• Co-payments: Are due at the time of service.
• Deductibles and coin-insurance: Will be billed to you once processed by insurance
• Outstanding balances: Must be paid in full prior to any routine visits and non-urgent chronic medication follow ups.
• Non covered services: Your insurance company may not cover all charges such as lab tests performed in the office, flu shots, well child care, and other medically indicated services. It is your responsibility to contact your insurance company to determine which charges may or may not be covered. Any noncovered services will be your responsibility.
• Credit Card on file: All patients must keep a valid credit card on file. We will automatically charge the card on file for the following: After hour phone calls, same day cancellation or no shows, and any past due balances billed to you not paid within 60 days.
• Newborn dependents: We hold a credit card on file for newborn dependents. If we are unable to verify coverage by the two-month visit, it is our policy to charge the card on file for any outstanding balances. Once baby has been officially added we will bill your insurance and will issue a refund once your insurance has processed and paid the outstanding claims.
• Medical records: The per-patient chart fee is $10. An additional $5 shipping fee will be added for records that are mailed. All records are provided on a disc. We can email records at no cost if the chart size is not too large.
• After hour phone calls: Oak Park Pediatrics charges $40 for after hour calls. This charge is not covered by your insurance and will be billed directly to you. You are utilizing the physician’s expertise outside of regular business hours and there are extra costs associated with handling patient calls when the office is closed.
• Late fee: a $15 late fee will be applied to all balances that have not been paid within 60 days.
• Returned checks: for non-sufficient funds will be billed an additional administrative fee of $25
• Collections: All balances which have not been paid within 90 days of first being invoiced will be deemed delinquent and referred for collections. All fees charged to Oak Park Pediatrics Ltd. relating to collection efforts associated with your account shall be your responsibility.
• Appointment/Cancellations/No Show policy: In order to efficiently care for all our patients, we request that you cancel or reschedule your child’s appointment no later than 24 hours prior to the appointment time. Oak Park Pediatrics Ltd. charges a fee of $75 for missed appointments or appointments that are not canceled/ rescheduled within 24 hours of the appointment time.
• Late arrival policy: In order to run on-time and diminish wait times for our families, we ask that you arrive a few minutes early to check in for your appointment. If you are late for more than ½ of your allotted appointment time, you may be asked to reschedule and this will be considered a missed appointment and subject to our NO-SHOW policy of $75.
• Well visit Policy: Well child care includes discussion about preventative care, tracking growth and development, and providing anticipatory guidance. Chronic or acute care issues that are discussed at the time of well child visits are subject to additional charges which may generate a co-pay or may be applied to your deductible. Our office is required by law to follow specific national guidelines set forth regarding billing for patient visits. Our goal is to provide convenience to our patients. We schedule longer checkup times to be able to address concerns and save your family from having to come back for a follow up office visit. In some instances, your physician may ask you to schedule a follow up appointment if all concerns cannot be addressed within the time constraint of the checkup. We encourage all families to know as much as possible about their insurance plans so they are not surprised by charges that may arise regarding the care of their child.

• Practice Policy for Divorced or Separated Parents: We respectfully ask that parents NOT place our office in the middle of family disagreements. We rely on parents to help keep our practice atmosphere calm, supportive and professional.

1. Illinois state law mandates that both parents have a right to access a child’s medical record and make medical decisions. If one parent’s role is legally restricted by Court Order, we ask that you provide this document, as well as a letter from your attorney stating our office’s specific legal obligations.
2. All co-pays, deductibles and balances are due at the time of service. Any parent bringing the child in is responsible for this amount even if the other parent is responsible for medical insurance or expenses. Please do not ask our office to collect payments from a parent who is not present at, and may be unaware of, the visit.
3. It is the responsibility of the parents to communicate with each other about pertinent information relevant to a child’s health outside of the office visit. Please do not ask us to routinely call/update the non-attending parent following visits.
   

• Code of Conduct: Our practice follows a zero-tolerance policy for aggressive behavior, intimidating language, and/or disparaging comments made in the office, over the phone, or via social media that are directed towards or are about our staff or physicians. These behaviors negatively impact the physician/patient relationship and may be grounds for dismissal from the practice.

1. If you have any questions about your child’s care, please ask to speak with a doctor or nurse.
2. If you are unhappy with the service received in our office, please contact our practice manager.

I agree to accept financial responsibility for medical expenses incurred at Oak Park Pediatrics Ltd. and to abide by the above stated policies. I authorize the release of any medical information necessary to process any claims, either to myself or to any parties who request this information.

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.