Office/Billing Policies

Payment Authorization Form

We are committed to meeting your healthcare needs and keeping your insurance and other financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner for all our patients, we ask that you adhere to our practice’s financial policy. By signing below, you are agreeing to its terms.

I am ultimately responsible for payment of charges for services I receive from this practice including those covered by my insurance. As a convenience, this practice will submit claims for reimbursement with my insurance provider; however, all payment responsibility is ultimately mine.

Some immediate payment may be expected at the time of service. This may include a co-pay and additional payment if this practice determines that the cost of my visit today will not be reimbursed by my insurance provider. This often happens if my deductible is not yet satisfied.

This practice may deny service or charge a service fee for failure to pay a co-pay at the time of service.

It is my responsibility to provide my current address, telephone number, email address, and insurance information at each visit.

I agree to provide the above practice and/or its designated payment agent with my debit/credit card information.

I understand that my signature and payment information will be maintained on file for future use by the practice. The applicable payment card or bank account number will be truncated and “tokenized” by the payment agent in order to help maintain the security of my payment information. Card or ACH Information will be obtained through card swipe, manual entry from card, void check, or orally in person or over the phone.

If warranted, this practice may offer the option of paying my share of costs via an automated payment plan. I understand that I may incur some interest expense beyond my balance in exchange for this convenience. I can avoid interest charges by paying my bill immediately if required or by its due date.

I authorize the above practice and/or its designated payment agent to apply charges to my payment card and/or bank account for all amounts owed to the practice for medical visits, procedures or supplies, including (i) amounts agreed as part of a payment plan, (ii) copayments, (iii) coinsurance (after application of insurance proceeds), (iv) amounts not covered by insurance and/or (v) fees (if applicable) charged by the practice for failure to keep a scheduled appointment or provide timely notice of appointment cancellation.

In the case of a patient balance that is not satisfied by a charge to my payment method or a payment plan, I may receive a monthly statement for any outstanding balance. I am responsible for paying this balance by its due date in order to avoid paying possible interest on the balance.

Transaction receipts will be printed and given to the patient or will be emailed to me if I provide and maintain a valid email address.

I authorize the above practice and/or its designated provider to send electronic account statements and invoices to my email address on file. I understand that it is my responsibility to maintain a current email address on file and that I will not receive a mailed copy of any electronic statement.

This authorization will remain in effect until I provide written notice of cancellation to the practice. Authorization for services already rendered cannot be cancelled or refunded. I agree to notify the practice in writing of any changes in my payment or other information.

Office Policies

Consent for Administration of Vaccines

This consent is to be reviewed and signed at the first office visit. The vaccine schedule recommended by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) is followed. Alternate schedules put children at risk for serious illness and as such, cannot be followed. Dr. Feldott and her staff do not wish to put patients and the public at risk by allowing refusal or intentional delay of vaccination. We are passionate about the need for vaccinating children, including your children and our own. Trust is a very important part of the physician-patient-parent relationship. Unfortunately, not trusting a pediatrician or nurse practitioner about the effectiveness and safety of vaccination may lead to lack of trust regarding other aspects of pediatric care. We do not wish to put you or us in that position. If vaccination is in no way agreeable to you, please find another local provider who might be able to accommodate your wishes for your child's care. If you do not wish to refuse vaccination, but simply want more education about the vaccines - what they do, when they are given, how the schedule is determined, etc. - please feel free to make an appointment and one of us can discuss this with you. Thank you in advance for your understanding in this matter.

After-Hours Call Service Fees Policy

A $15 fee will be billed to all patients for after hour calls. We will not be billing insurance companies for these fees. It is fully the patient’s responsibility.

After-hours Call Service

Please limit after-hour calls to urgent issues and emergencies.

For refills, appointment requests, and other non-urgent matters, you may call the

office during regular hours.

NO SHOWS/CANCELLATION APPOINTMENT POLICY

Repeated No Shows or Cancelled appointments by a patient will not be tolerated. Appointments must be cancelled at least 24 hours in advance otherwise it will fall within the No Show/Cancellation policy.

Reminder calls are done as a courtesy when time permits, however, they are not MANDATORY and ultimately, it is your responsibility to keep track of your child’s appointment.

A $25 No Show/Cancellation fee will be charged for each No Show/Cancellation. Fee is payable at the next appointment.

First No Show/late Cancelled appointment will be documented in the patient’s chart & a $25 fee will be due at next office visit.

With the second No Show/Cancelled appointment, a letter will be sent to the patient stating that this is an unacceptable practice that is not fair to other patients and will not be tolerated & a $25 fee will be due at next office visit.

The third No Shows/Cancelled appointment, the whole family will be terminated from our practice.

WELL CHILD/ADHD/PHYSICAL APPOINTMENTS POLICY

Parent or Guardian will accompany the patient on all well child, ADHD, and Physical Examination appointments.

This is required, as the parent or guardian must be available to sign authorizations to administer various immunizations and must be present to answer family history and medical history questions by the physician.

If patient arrives without the parent or guardian the appointment will be rescheduled unless parent/guardian has filled out and signed a designation of authorized adult representative form.