Patient Agreement

INSURANCE PLANS:

I understand it is my responsibility to confirm with my insurance company that the physician is currently under contract with my plan or be willing to be seen under "out of network" benefits.

COVERAGE:

I acknowledge that Northwest Suburban Pediatrics, S.C. is not responsible to know what services my insurance covers. I shall direct questions regarding health insurance policy coverage to my insurance company.

FINANCIAL COMMITMENT:

I agree to be responsible for all copays, deductibles and non·covered services determined by my insurance plan at the time of my visit. If I do not have a copay or have not come prepared to pay past due balances, my child's appointment may be rescheduled for a later time. Furthermore, I understand that if someone other than me is bringing my child to Northwest Suburban Pediatrics, S.C, they will be responsible to pay for copays and any past due balance. Even in divorce situations, we consider both parents responsible for the account. In the event the account is referred to a collection agency a 30% collection fee will be assessed, both parent's names and social security numbers will be submitted.

NO INSURANCE AT THE TIME OF SERVICE:

If proof of insurance coverage cannot be determined at the time service, I understand that payment is required at the time services were provided. In some circumstances, I may have the option to put a credit card or debit card on hold until I'm able to provide proof of insurance.

PAYMENTS:

I will promptly pay all amounts that have been determined my responsibility by my insurance carrier upon receipt of my statement. Any balance remaining after my health insurance processes a claim is my responsibility.

SERVICE FEES:

I understand my account will be charged $35 for NSF/Returned checks.

PERMISSION TO TREAT:

I give permission to Northwest Suburban Pediatrics, S.C. to render treatment to my minor children.

APPOINTMENTS & LATE ARRIVALS:

I understand that it is important to arrive on time for my appointment. I'm also aware that if I arrive more than 15 minutes past my scheduled appointment time, the practice may have to reschedule my appointment.

NO SHOWS:

I commit to give Northwest Suburban Pediatrics, S.C. at least 24 hours notice if I am unable to keep my scheduled appointment. I understand Northwest Suburban Pediatrics, S.C. does charge a $25 fee for no-shows if practice is not notified; however, if I miss 3 appointments without notifying the practice in a 12 month period, the practice will no longer be able to continue providing pediatric healthcare services and I understand I will be dismissed from the practice.

MINORS:

If my child is not accompanied by a legal guardian, I agree to provide written authorization for medical treatment so that treatment can be rendered. I also agree to be available by telephone in the event that the physician needs to contact me.

PRACTICE ACKNOWLEDGMENT:

I have received the notice of privacy and I have been provided an opportunity to review it.

AUTHORIZATION TO RELEASE INFORMATION TO THE INSURANCE CARRIER:

I hereby authorize Northwest Suburban Pediatrics, SC. to release any information required in the course of my examination or treatment which could include HIV, communicable disease or drug abuse information.

I have read, understood and agree to the above financial and office policy. I understand that Non·compliance with this policy may result in a dismissal from Northwest Suburban Pediatrics, S.C.

Patient Name:

Date of Birth:

Sibling Name:

Date of Birth:

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DISCLAIMER: 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

Parent or Guardian's Signature:

Date:

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