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We at Neighborhood Pediatrics (NEIGHBORHOOD PEDIATRICS) are committed to providing quality care and we are pleased to discuss our fees for professional services with you at any time requested. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about this financial policy.


We bill your insurance carrier solely as a courtesy to you. If you are enrolled in a plan we have a contract with, you are only required to pay the co-payment/deductible/co insurance at the time of your visit. We require that arrangements for payment of your estimated share be made before being seen by the physician. If your insurance carrier does not remit payment within 45 days, the balance will be due in full from you. In the event that your insurance company requests a refund of payments made, you will be responsible for the amount of money refunded to your insurance company. In the event your company establishes an internal usual and customary fee schedule, you will be responsible for the difference remaining.

If any payment is made directly to you for services billed to us, you recognize an obligation to promptly remit same payment to Neighborhood Pediatrics.

You expressly authorize the physicians of Neighborhood Pediatrics to electronically debit your account for the amount of the check plus a processing fee of up to $35.00, if your check is dishonored or returned for any reason. In accordance with the rules of the National Automated Clearing House Association, you may call (888) 235-4635 to revoke the authorization for the electronic transaction. This does not mean, however, that Neighborhood Pediatrics cannot collect a return check fee by other methods.

UNACCOMPANIED MINORS: Minor must have an authorization for medical treatment signed by his/her parent/guardian and is responsible for providing current insurance information for self. Please note that co-payments and/or deductibles are expected at the time of service.

REGARDING DIVORCE: NEIGHBORHOOD PEDIATRICS does not get involved in disputes between divorced parents regarding financial responsibility for their child’s medical expenses. Payment is the responsibility of the parent who brings the child in the office for treatment. This is regardless of the terms outlined in a divorce decree. This is a matter between the divorced parties and the courts and we cannot be placed in the middle. If the divorced parents cannot agree on treatment for their child we may not be able to continue to treat them.

REGARDING INSURANCE: Indemnity/Fee for Service: We require full payment at the time of service. We will supply you with a copy of your itemized statement so that you can file for reimbursement from your insurance company. Should your insurance company require a more detailed description of services, please have them request it in writing.

REGARDING BEING LATE: Arrival g reater than 15 minutes after appointment time will result in a $25 late fee and the option to reschedule or be seen in the next available time slot if one is available. If no time slot is available you will need to reschedule. APPOINTMENT CANCELLATION / NO-SHOWS: Failure to provide 2 4 hours notice when canceling said appointments, or not showing uu p for your appointment will result in a $50 fee being assessed, as these appointment times could have been given to another patient(s) in need. Please be advised that reminder phone calls and emails are made as a courtesy to you and do not relieve you of the responsibility for remembering your child’s appointment.

We D O NOT ACCEPT, third party insurance, social security or auto accident claims. We only accept and file with your primary and secondary insurance. If you do not tell us of primary insurance commercial plans and your payment is denied through Medicaid, you will be responsible for that amount.

Insurance is a contract between you and your company. We are not a party to your contract. We will not become involved in disputes between you and your insurance company regarding deductibles, non-covered charges, co-insurance, secondary insurance, coordination of benefits, pre-existing conditions, or “reasonable and customary” charges other than to supply the factual information as necessary. You are responsible for timely payment of your account.

· I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees and attorney fees.

· I have read and understand that I am personally responsible for payment on this account.

· Assignment: I hereby authorize payment directly to NEIGHBORHOOD PEDIATRICS or my Physician. Any changes in this authorization must be received in writing within 30 days of the effective date.

· In the event my insurance company deems a service to be “non-covered” I understand that I am personally responsible for payment.

· I agree to the release of any and all medical information, including HIV test results, and financial information necessary to process this and any future claims to my insurer or payer of health benefits, as I may designate that person or entity from time to time, for an indefinite period or until I submit a written revocation of this release. Any changes to this authorization must be received in writing within thirty days of effective date.

Billing is automated and accounts over 90 days past due are automatically turned over to an agency for collection. There is a $25.00 fee if we have to turn your account over to an agency for collection. We do accept MasterCard, VISA, and Discover for your convenience.. These fees are not covered by your insurance plan.

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