Office Policies & Business Policies

OFFICE POLICIES

PATIENT PRIVACY

Young Pediatrics complies with the federal Health Portability and Accountability Act (HIPAA). We follow the terms of our office Notice of Privacy Practices, which may be changed/updated periodically. Our Notice of Privacy will be effective on all protected health information we maintain. A copy of our current HIPAA statement is available upon request.

DISCLOSURE OF HEALTH RECORDS

Patients > 18 years of age must sign a waiver authorizing parental access to their account. In compliance with Illinois law some information for patients >12 years of age require the patient sign a waiver authorizing parents to have access. Records to be sent to a specialist our providers have referred you to do not require a signature. School Certificate of Examination forms and/ or Sports Participation Exam forms can be faxed directly to school/camp with a verbal request from parent/guardian or patient if > 18 years.

MEDICATION REFILLS and PRIOR AUTHORIZATIONS

You may request a refill of chronic medications through our patient portal or calling the office and selecting the refill line (option 4). Medication refills may require medication re-check visit. Prescriptions will be sent to the preferred pharmacy on file unless otherwise requested. Medications that are classified as “Controlled” require at least 5 days notification. Refills requested after 4pm may not be retrieved until the next business day

AFTER-HOURS CALL SERVICE

Please limit after-hour calls to urgent issues and emergencies. For refills, appointment requests and other non-urgent matters you may send us a message through the patient portal (these are checked during regular office hours) or call the office during regular office hours.

APPOINTMENTS

Scheduling: You may schedule most appointments through our patient portal self-scheduling feature. You may also schedule by calling our office at 618- 288-9305 option 1.

Arrival: To allow time for insurance and demographic information, and/or completion of any paperwork, we ask that you arrive 15 minutes early for your appointment.

Late Arrivals: if you are >5 minutes late you may be moved to the next available appointment that day or rescheduled to another day.

Missed Appointments: If an appointment is missed or cancelled without 24 hours’ notice a fee of $50 will be charged (insurance does not cover this fee). A patient/family that has 3 or more missed appointments within a 12-month period will result in dismissal from the practice.

Walk-in/adding a sibling: An additional $10.00 convenience fee will be applied for the add-on. If you have another child that needs to be seen, we ask that you call the office. Appointments may need to be moved to a different time to accommodate multiple appointments.

DUAL HOUSEHOLDS

Patients who have caregivers in 2 households will be listed under the address on file with their insurance.

If there is Court ordered/provided custody agreement, we request a copy for the patient’s chart.

If the custody agreement states that both parents have Healthcare decision making, we ask that both parents sign the policy acknowledgement.

CONDUCT

We expect parents to refrain from yelling, and using offensive language in our office. We strive to create a safe, calm, and comfortable place for our patients and to give them the best care available.

SERVICE DOGS

In accordance with the Americans with Disabilities Act (“ADA”)1 and for the benefit of our patients and families at Young Pediatrics, this policy serves to notify patients and service dog handlers of their rights regarding service dogs in our office.

It is the policy of Young Pediatrics to afford individuals with disabilities, who require the assistance of a service dog, equal opportunity to access our office. Young Pediatrics allows service dogs to accompany individuals with disabilities in all areas of our office in which the public is generally allowed. This includes waiting rooms, patient rooms, and accessible hallways. The ADA defines service dogs as those dogs trained to perform tasks which are directly related to a disability of an individual. Dogs whose sole function is to provide comfort or emotional support do not qualify as service dogs and are not permitted in our office. We reserve The right to inquire into whether a dog in our office has been trained to perform tasks related to a disability and may ask handlers of those which are not trained for a disability to remove the dog from the office.

Further, service dogs in the office must be harnessed, tethered, or leashed at all times. Our office may ask the patient and/or handler to remove the animal if:

1. The dog is out of control and the handler does not take effective action to control
2. The dog is not housebroken.

A service dog is considered out of control if it is continuously barking, snapping at patients/staff, wandering around sniffing patients, or exhibiting other behaviors that would not normally be seen by a trained service dog. In this case, we will ask the handler to try to gain control of the dog, however, if the dog remains out of control, we reserve the right to ask the handler to remove the service dog.

The American with Disabilities Act (ADA) (28 C.F.R. Part 35) is a federal law that prohibits against discrimination on the basis of disability

As a parent of a patient of Young Pediatrics I acknowledge their Policies and Practices and do hereby agree to follow them.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

BILLING POLICIES

CO-PAYS

All co-pays are due at the time of service. If they are not received, they are subject to an extra $10 charge for extra billing procedures that will need to be performed. This charge is the responsibility of the patient and will not be billed to the insurance company.

PAYMENTS

Payments must be made at each visit, or at a minimum of regular monthly payments may be set up. Contact our billing office for details. Nonpayments may result in termination from the practice

NON-CLINICAL FEES

Patients will be responsible for any non-clinical fees accrued, such as missed appointments, forms, or walk-in fees

NON-COVERED/PATIENT RESPONSIBILITY SERVICES

There may be diagnostic tests, procedures or surveys completed that are not covered by your insurance or are covered but applied to patient responsibility, coinsurance, or deductible. It is your responsibility to know your individual policy and make a payment of these charges.

COLLECTION CLAUSE

We make several attempts to contact families and set up a reasonable payment plan and only turn over to collections as a last resort. In the event the responsible party fails to pay pursuant to the terms of the contract Young Pediatrics reserves the right to pursue all available legal remedies pursuant to the laws of the State of Illinois. Should your claim be referred to a collection agency and/or attorney for collections, the customer will pay all necessary costs of collection, along with all legal fees with interest to be accrued at the annual rate of 10 % per annum. At this point, the relationship between provider and patient (entire family) will be terminated. Phone calls and letters are sent out as a courtesy prior to being turned over to the collection agency. If no response in the designated time frame, they are sent on.

RETURNED CHECK FEE

There is a return check fee of $35 per check returned from your institution. This is necessary as we are charged by our financial institution. In the occurrence of a returned check, you may be restricted to cash/card payments only.

CHANGES

Any changes of insurance, address, or phone numbers must be given at the time of visit or prior by portal or phone. Current insurance cards must be presented at each visit. If an insurance change is made, we must have all the information…ID#; Group# & Billing mailing address (on back of card) as well as Parent carrying the insurance with their birth date & SS#.

We hope this information will help all our patients to prevent any confusion with your insurance company for you. We are dedicated to making the health of your child a priority and easy experience, while providing the best care for your child. If you have any questions please reach out to us by messaging through the patient portal or by calling our billing office at 618-288-5502 or 618-288-9305 option 3.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

As a parent of a patient of Young Pediatrics I acknowledge their Billing Policies and Practices and do hereby agree to follow them.