We appreciate your loyalty and strive to have Well Child and Same Day Sick appointments available for your convenience.
Please be courteous. If you are unable to attend an appointment please notify us so we may offer your time slot to another family.
Insurance policies and coverage can be confusing and complex based on individual plans. To avoid unexpected charges, it is important that you fully understand your insurance coverage benefits and limitations. Your insurance policy is a contract between you and your insurance company, and we are not able to modify coverage, copayments or deductibles. Having insurance is not a substitute for payment. It is your responsibility to pay the deductible, coinsurance, and any other balances not paid for by your insurance.
If your child is being seen for a well check and one of our providers treats your child for: 1. A sick condition, 2. A follow-up on an existing ailment. 3. Or performs a procedure -In addition to your annual physical, you will be billed a copay, co-insurance or deductible amount according to your insurance benefits.
Southwest Children’s Clinic, LLC will not get involved in custodial, separation or financial disputes involving or related to divorced parents of a minor child. The parent who is the guarantor for the insurance policy covering the child is the responsible party. If the child is not covered on an insurance plan the guarantor is the parent who completed the office paperwork.
I authorize the release of all medical information necessary to process each medical claim and all information that is pertinent to my child’s medical care. I authorize payment directly to the physician or clinic for all medical or surgical benefits to which my child is entitled. Should any unpaid balance be referred to a collection agency I agree to pay an additional collection fee up to 30% with or without suit. I also agree to pay reasonable attorney fees and court costs should suit become necessary. A photocopy of this assignment is to be considered as valid as the original. I hereby consent to being contacted by telephone at any telephone number provided by me or anyone associated with me or acting on my behalf to Southwest Children’s Clinic or anyone acting on its behalf. I understand and agree that such calls may be initiated by Southwest Children’s Clinic or any of its affiliates, agents, contractors or assigns, including but not limited to billing companies and/or third-party collection agency(ies), and that the methods of contact may include using pre-recorded/artificial voice messages and/or the use of an automated dialing device and/or the use of text messages—some or all of which may result in data charges. I also consent to receiving e-mails at any e-mail address provided by me or anyone associated with me or acting on my behalf. Utah law requires Southwest Children’s Clinic to provide the responsible parties with notice, by certified/priority letter or text message, 45 days prior to placing any delinquent balance with a collection agency or reporting any delinquent balance to any credit bureau, which actions may negatively impact my credit score. I understand I will be charged a fee of $10.00 if any such notice is sent to me.
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:
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