We are committed to providing you with the best care, and we are available to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important. Please ask if you have any questions about our fees, financial policy, or your responsibilities.
EACH DOCTOR AT THE PEDIATRIC CENTER BILLS SEPARATELY
WE ARE NOT PARTY TO ANY LEGAL AGREEMENT BETWEEN DIVORCED OR SEPARATED PARENTS
FULL PAYMENT FOR SERVIES IS DUE AT THE TIME SERVICE IS RENDERED unless other arrangements have been made with this office. We accept cash, personal checks, VISA, Mastercard and American Express.
HEALTH INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. YOUR DOCTOR’S BILL IS AN AGREEMENT BETWEEN YOU AND YOUR DOCTOR.
INSURANCE PROGRAMS THAT CONTRACT DIRECTLY WITH US – YOU ARE RESPONSIBLE FOR UNDERSTANDING THE POLICY YOU HAVE CHOSEN, please read the benefits of your individual policy and provide our office with all necessary billing information. There are some services that may not be covered by your insurance. Payment is expected at the time of service for non-covered charges. COPAYMENTS ARE REQURIED AT THE TIME OF SERVICE.
INSURANCE PROGRAMS THAT DO NOT CONTRACT DIRECTLY WITH US – YOU ARE EXPECTED TO PAY IN FULL FOR ALL SERVICES. We will give you a receipt to file a claim with your insurance company. You are responsible for your bill regardless of the status of an insurance claim.
EASYPAY SYSTEM The Pediatric Center employs the EasyPay Card-On-File system for outstanding patient owed balances. All responsible parties are required to give us a credit card number to be kept on file. This information is kept secured and encrypted. After we hear back from your insurance carrier any outstanding balance will be applied to your credit card and a receipt will be emailed to you. Only in extreme cases may this policy be overridden. This must be approved by our business office and a $5.00 paper bill charge will be applied for each bill.
DELIQUENT ACCOUNTS - Delinquent accounts may be referred to a collection agency. If your account is sent to collections, your child will no longer be seen by any doctor in this office. You agree that if it becomes necessary to forward your account to our collection agency, in addition to the amount owed, you will also be responsible for the fee charged to us by the collection agency for costs of collections, reasonable attorney fees, and any additional court costs awarded by the court.
APPOINTMENT CANCELLATION POLICY – We require a 24 hour notice of cancellation for all scheduled appointments, or you may be billed for that appointment. Insurance will not cover this charge.
REFERRALS – If your insurance plan requires a referral for any services outside of this office PLEASE CONTACT THE BUSINESS OFFICE BEFORE SCHEDULING SUCH SERVICE. Referrals must first be authorized by your physician and any necessary paperwork will be completed by our business office. IT IS YOUR RESPONSIBILITY TO OBTAIN AUTHORIZATON AND TO KNOW WHICH HOSPITAL, LABORATORY ETC. YOUR INSURANCE REQUIRES YOU TO USE.
If unusual circumstances make it impossible for you to meet the terms of this financial policy, please discuss your account with our business office, this will avoid misunderstandings and enable you to keep your account in good standing.
I HAVE READ AND UNDERSTAND THE ABOVE POLICIES, AND I AGREE TO ACCEPT RESPONSIBILITY FOR ANY FINANCIAL OBLIGATIONS INCURRED.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.