Payment is required at the time services are rendered. The person who brings the patient to the office is responsible for payments due at the time of service unless arrangements have been made in advance. This includes applicable coinsurance and copayments for participating insurance companies. Pediatric Specialists of Tulsa accepts cash, personal checks, check cards, VISA, MasterCard and Discover. There is a service charge for returned checks. If there is a returned check on file all future payments must be made by cash, money order, cashier’s check or accepted credit cards.
We will collect upon check in, our average level of service. If anything else is done such as lab, x-ray, immunizations, etc., or the visit requires more than the average level of service, you will be expected to pay the difference upon checking out.
The billing statement will be sent to the house in which the patient resides. If payment responsibility has been otherwise designated, it will be the responsibility of the statement recipient to properly communicate to that party. We will not be the mediator or get in the middle of a divorce or parental separation agreements.
Our Practice makes every effort to collect what is owed to us, including engaging the services of a collection agency for bills that go unpaid. Therefore, if bills go unpaid for more than 60 days, such debts may be transferred to the collection agency. Additionally, patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling their next appointment(s).
We bill participating insurance companies as a courtesy to you. You are expected to pay your deductible, co-insurance and copayments at the time of service. If we have not received payment from your insurance company within 45 days of the date of service, you may be expected to pay the balance in full. You are responsible to be sure all charges are paid whether by you or by your insurance carrier.
Refunds will be promptly refunded to the credit card on file.
Missed Appointments/Late Cancellations
Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the office visit or well visit appointment, 48 hours for consult appointments. We reserve the right to charge for missed or late-canceled appointments. Excessive abuse of scheduled appointments may result in discharge from the practice.
I have read and understand the Financial Policy. I agree to assign insurance benefits to the Pediatric Specialist of Tulsa practice whenever necessary. I also agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collections.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.