Thank you for choosing Atlanta Children's Clinical Center, P.C. as your health care provider for your children. Each day we strive to exceed your expectations as valued patients, parents and guardians, through excellent medical care and exceptional service. As a part of your relationship with us, a clear understanding of our financial policies is important so you will know what actions we will be undertaking on your behalf as well as what your financial responsibilities are to us. Your health insurance policy is a contract between you and the insurance company. You have certain responsibilities to ensure that proper, accurate and timely submission of charges occurs. We will not become involved in disputes between you and your insurance company and will only provide accurate, truthful, and factual information to facilitate claim processing.
Present the proper most current insurance card for your children) at the time of service. You must bring a valid card to every visit. Please inform the receptionist of your child(ren) in the practice to which any new insurance information needs to be applied. If insurance cannot be verified payment is expected at the time of service.
Inform the receptionist of any changes to your contact information including current address and phone numbers.
Pay your co-payment at the time of service, even at follow-up visits. A $10 service fee will be applied to the account for non-payment of co-payments at the time of service if not paid by end of day.
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, deductibles, and non-covered services due to policy limitations and any outstanding balances after your insurance company has submitted payment to Atlanta Children's Clinical Center, P.C.
Proceed to/stop at check-out after your visit to pay account balances and schedule a future appointment.
Pay your account balance in full within 30 days of receiving Atlanta Children's Clinical Center, P.C.'s statement of outstanding charges unless other arrangements have been made with our Business Office. If your payments are not received in a timely manner and your account is not kept current, your account will be sent to Atlanta Children's Clinical Center, P.Ci's Third Party collection agency and the collection fees will be your responsibility. If bills continue to go unpaid, Atlanta Childr&n's Clinical Center, P.C.
reserves the right to dismiss you from the practice.
You are responsible for knowing the benefits and provisions of your particular insurance plan. If you have any questions regarding your benefits, please contact your carrier prior to your visit and if necessary during your visit before questionable services are rendered.
We request that you be able to provide valid insurance coverage at every office visit. If we are unable to verify coverage, any and all fees for your services are due on the date of service. Insurance claims are filed as a courtesy on your behalf. We do not file to secondary health insurance companies, you will be responsible for submitting claims to that carrier. You must report any insurance changes to the office as soon as possible. Any information that is inaccurate, or received after the date of service may not be billable to the insurance carrier (in some cases), and may become the responsibility of the account guarantor.
In most cases newborns need to be added to your insurance plan within 30 days from the date of birth. Please check with your employers' human resources department. If insurance cannot be verified after 30 days of life for a newborn payment will be due on the date of service for your child. Furthermore payments during the first month of life will also be due.
Prior-Authorization may be required by your insurance company for medication, for tests, including lab and radiology, procedures, specialist referral visits or hospital admissions. While we try to assist our families with these guidelines it is the responsibility of the policy holder to know and understand these requirements to avoid any costly penalties and denials by your insurance company. We ask for 72 hours to complete insurance referrals, some insurances will not process retroactive referrals.
Even though you have health insurance, you as the guarantor are responsible for payment of all services provided by Atlanta Children's Clinical Center, P.C. We will bill your insurance for services rendered, with the information you have provided us. If your insurance information has changed please notify us immediately so that we may bill the correct insurance carrier and avoid timely filing denial. If you provide us with insurance after the timely filing period (most cases 90 days) the balance will remain your responsibility.
Atlanta Children's Clinical Center, P.C. will submit claims only to your primary health insurance company for services rendered. Once your insurance company has processed your claim we will post any payment and/or contractual adjustments to your account. Any remaining balance will be your responsibility. This balance may include your deductible, co-payment, co-insurance and any non-covered charges. As stated before, we request that you pay your balance in full within 30 days of receiving your statement.
Atlanta Children's Clinical Center, P.C. Accepts payment via cash, check, credit card (Visa, MasterCard, Discover, and American Express). Payments can also be made online at www.atichildrens.com by clicking on "Pay my bill". Please be advised that when paying your fees such as no show, walk-in, annual administrative, or returned check fees, etc. that are not covered by your insurance company, you may not use your HSA (health savings account) card.
Your health insurance policy may state that you must pay a co-payment for all physician visits. This payment is due the day of service. If, for any unforeseeable reason, you do not have the co-payment at the time of service, please be aware that Atlanta Children's Clinical Center, P.C. will be charging you an administrative surcharge of $10.00 for processing your co-payment after your visit. Atlanta Children's Clinical Center, P.C. has a contractual agreement with the health insurance carriers to collect all co-payments on the date the services are rendered.
Atlanta Children's Clinical Center charges an annual administrative fee of $20 per child for administrative services you may require throughout the year including camp forms, school forms, immunization records (3231), hearing and vision records (3300), etc. This fee also covers services insurance does not cover including nurse phone time to handle prior-authorizations, medication renewals, and billing account history printouts for tax purposes, etc. Forms requested for same day completion will incur a $25 rush fee and the form will need to be requested no later than the morning of and is guaranteed by close of the day. Please verify that your child is up to date on their annual well-check/physical exam.
Missed appointments and late cancellations/rescheduling represent a cost to us, to you and other patients who could have been seen in the time set aside for you. We require at least a 24hour notice for any cancellations or rescheduling of well-check appointments. We require you to cancel a morning sick appointment by 8:30am and and afternoon appointment by 1:30pm if scheduled the day before. If scheduled the same day please call us as soon as possible to cancel. We have a scheduling voice mail in order for you to leave a message outside of office hours to do so for your convenience. Failure to do so iradvance will result in a $25.00 administrative fee per appointment. These fees are not covered by your insurance company and are the sole responsibility of the guarantor on the account. If you are late for your appointment (> 15 minutes), we will do our best to accommodate you. However, it may be necessary to reschedule your appointment.
We see patients on an appointment only basis. We strongly discourage walk-ins. If you bring your child in as a walk-in we will try our best to accommodate you and will offer you the next available appointment on that day.
You may wait or come back at the appropriate time. We want to accommodate every family's needs on the same day but we first honor the appointments previously scheduled in an efficient manner. There will be a $25 fee that must be paid on the date of service if you walk-in and disrupt the daily schedule, meaning if there are no slots left available to add your child to in order to be seen you will be charged. The fee may also be charged at the discretion of the Physician. Patient's who make walk-ins a habit are subject to dismissal from the practice for not complying with policy and procedure.
It is our hope that we never have to dismiss anyone from our practice. However, Atlanta Children's Clinical Center, P.C. will not tolerate certain behaviors that disrupts our practice and prevent us from maintaining a mutually cooperative and trusting physician-patient relationship. If you are dismissed from the practice it means you can no longer schedule appointments, get medication refills or consider us to be your child's doctor. You will have to place your child in the care of another physician. We will refer you to someone if you need us to do so.
Common Reasons For Dismissal
Failure to keep appointments, frequent no-shows, frequent walk-ins
Noncompliance, which means you will not follow physician instructions about an important health issue
Threatening or abusive behavior either verbally or physically to the staff, physicians or patients
Failure to pay consistent with our financial policy
The patient or parent is deceptive (ex. lies or attempts to abuse medication)
We will send a letter to your last known address notifying you that you are being dismissed and the account will be notated. If your child has a medical emergency within 30 days of the date on the letter, the doctor will see the patient. After that, you must find your child(ren) another doctor. We will forward a copy of your child's medical records to the new doctor after you let us know who the new PCP is and the medical release form is signed.
We are open on Saturday mornings generally for sick appointments only. It is up to the doctor's discretion to complete well-check appointments on their Saturday and those must be scheduled in advance. Sick appointments can only be scheduled same day on Saturdays.
Atlanta Children's Clinical Center P.C. 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 for the child(ren) will be the responsible party for payment of services rendered. Please be advised that whomever brings the children) in is responsible for the co-payment and/or balances at the time of service. For your convenience, a payment may be made over the phone at the time of service or prior to service on the same day by another party. Receipts will be provided after payment.
Requests for medical records require a signed medical release form stating the authorization of release from Atlanta Children's Clinical Center, P.C. to either the parent or new physician's office. After 1 copy of medical records is given, there will be a charge in accordance with the guidelines set forth by the state of Georgia for additional copies of medical records. All medical records will be subject to a processing fee and will only be released after the fee is collected. Please be advised we do not mail records to your home address, you may pick them up or we will send them to a new physician, either by fax or mail depending on their policy. Patients transferring in to our practice are required to have their complete record transferred to us before any appointment scheduling can be completed.
I have read the above financial policy for Atlanta Children's Clinical Center, P.C. and I agree to the terms listed above
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