Secure Financial Policy Form

Pediatrics at Newton Wellesley, P.C.

Please correct the errors described below.

Patients are responsible for providing us with current insurance information prior to receiving services. In order to file a claim on your behalf and verify your identity in accordance with federal law, we require that you present your insurance card. We may ask you to update your insurance and contact information periodically.

We are participating providers with many insurance carriers. However, if we do not participate with your insurance plan and you do not have out-of-network benefits, you will be considered a self-pay patient.

While we make attempts to verify your insurance benefits prior to your appointment, patients are strongly encouraged to contact their insurance company and be familiar with their plan benefits and financial responsibilities, such as deductibles. We are not permitted to waive patient co-payments, co-insurance or deductibles under our contractual carrier agreements and federal law. Your financial responsibility will be reflected on your insurance carrier’s Explanation of Benefits.

For those families where parents are separated or divorced, the parent authorizing treatment and/or bringing the child to be seen is responsible for the co-pay at the time of visit.

We ask that you provide us with at least 24 hour notice for rescheduling or cancellation of appointments. We reserve the right to charge a fee of $40.00 for no-show/no-calls, which is not billable to insurance carriers. The fee for returned bank checks is $40.00.

PNW assigns delinquent accounts to a collection service. In the event your account is sent to collections, all family members’ accounts will be inactivated until the billing issue is addressed.

I hereby acknowledge that I have received and read Pediatrics at Newton Wellesley PHI and Financial Policy and agree to comply.

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