NON-COVERED AGREEMENT FORM

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We pride ourselves on providing only the highest quality care for your child and do this by following the American Academy of Pediatrics clinical guidelines and other trusted sources for evidenced-based clinical outcomeinformation. However, insurers rarely keep pace with guidelines, and do not want to cover services related to meeting these clinical recommendations. In fact, insurance company rules and policies change all the time. For example, your child’s hearing and vision screening may have been covered at your last visit, but that is no guarantee that your insurer will cover the same screening at this visit. Frustrating, isn’t it? And often we only find out that a plan is no longer paying for something when they send us a payment denial for a bill. It’s unfortunate for both of us, as we waste time and effort having to find out why payment was denied and then have the expense of billing you for it, while you, in addition to your copay / coinsurance / deductible cost sharing, may now have a ‘non-covered service’ to pay for too. Your insurer may already have a policy in place whereby it does not cover things like in-office strep testing and urinalysis, to name a few. You can verify with your insurer which services it covers and which it does not. Performing tests in-office is a quick and more efficient than sending tests out to labs, and performing screenings such as hearing and vision tests avoids incurring the inconvenience and expense on your part to refer you to a specialist for these things. As prompt and appropriate treatment of your child is of primary importance to us, we ask that you sign below that you understand that some of screenings and tests may not be covered by your insurance.

Below is a list of the most frequently provided services you can use to determine coverage with your insurer.

  • Vision Screening
  • Hearing Screening
  • Behavioral Screenings
  • Hemoglobin Test
  • Throat Culture
  • Urinalysis

If you do not wish for your child to have any of these tests or screening exams, please inform the staff at the beginning of your visit. Please realize that in doing so it may be necessary to send a test to an outside lab, refer you to a drawing station, or schedule a visit with a specialist in order to obtain the necessary information. This may significantly delay diagnosis and treatment, return to school or activities, or the provision of requested forms. I acknowledge that I have been informed in advance of receiving these services, that these services may not be covered by my insurance plan. I understand that I will be financially responsible for the amount not covered by my insurance.

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