Full payment is expected at the time of services are rendered and for all past due balances unless prior financial arrangements have been made with our management staff.
Payment is due regardless of who brings the child in for the service, Grandparents, caregivers, aunts, etc., payment is expected.
It is the parent's/guardian's responsibility to notify the office of any address, phone, or insurance changes. The parent/guardian will be responsible for any service rendered where they have failed to provide current or correct insurance information prior to being seen. Please have your insurance card with you at every visit.
For families in which parents are separated and/or divorced, the parent bringing in the child to the office is authorizing treatment and is, therefore, the parent responsible for payment on the date of service. If there is a divorce decree requiring the other parent to pay a portion or all of the treatment costs incurred, it is the responsibility of the authorizing parent to collect from the other parent. We can provide a copy of the claim or receipt of charges to the authorizing parent at each visit upon request to assist in the collection of fees from the other parent.
Insurance must be provided and active in order to utilize your benefits. If insurance cannot be determined as active, the patient will be considered Private Pay for that visit.
Private Pay patients with no insurance are provided a discounted rate. Payment must be received in full at the time of service.
Financial responsibility is determined from the benefits we receive from your insurance company. Your insurance determines if you have a copay, deductible and/or coinsurance.
Insurance co-payments are due at each and every visit. Please note that we are required by the insurance company to collect them. IF your insurance plan has a deductible and it has not been met for the year, you may be required to pay for the visit in full. If your insurance does not pay for services provided, then the parent/guardian is responsible for those charges. Verification of insurance is not a guarantee of payment; you are still responsible for all services provided to your child.
Acceptable forms of payment include cash, check, Visa, MasterCard and Discover. A fee of $25.00 will be assessed to all returned payments.
No Show or Cancellation Fees
$50.00 fee applies to all Well Child Visits and ADD/ADHD visits, cancelled less than 24 hours prior to appointment time and No Shows to appointments.
$25.00 fee applies to all other No Show appointments.
By signing this form, I am agreeing to the above financial policies. I understand that this agreement will be in effect until I revoke it in writing.
By printing your name in the signature box, this is confirmation of e-signature.