1. It is the policy of our office to collect co-payment/co-insurace/deductible at the time that services are rendered. Any amount due at the time of service that is not collected will be assessed at a $10.00 billing fee. We accept Cash/Visa/ Mastercard/Discover/American Express. We also accept personal checks, however, if a check is returned by the bank, there will be a $25.00 check return fee.
  2. For all services rendered to minor patients, we will ask the adult accompanying the patient or the parent/guardian for payment. We will not get involved in arrangements made between divorced parents or custodial agreements.
  3. Any services that are deemed to be the family's responsibility (additional co-pay, co-insurance, deductibles, or services considered non-covered by your insurance) will be applied to patient balance and will be due immediately.
  4. Any services that we file with your insurance that are not reimbursed after 60 days from the date of service may be transferred to patient balance. This balance will remain the responsibility of the family until payment is received or written correspondence is received by the insurance company verifying that payment is forthcoming from them. Any balances not paid in full within 90 days will be forwarded to the collection agency, unless prior arrangements have been made. Appointments will not be scheduled until the balance has been paid in full or an approved payment arrangement has been made.
  5. We must have your child's insurance card or written verification from your insurance company that your child is currently eligible for benefits no later than the 2 month check-up. If you do not have this available, then the visit will need to be paid in full or payment arrangements must be made regarding the previous balance. Any credit amounts will be refunded to you once insurance information is received and dates of service are paid by the insurance.
  6. If we do not participate in your insurance plan, we ask that you pay in full at the time services are rendered. We provide families without health insurance a private pay discount.
    As a courtesy, we allow 15 minutes for tardiness. After 15 minutes, we reserve the right to either fit you in as a walk-in or reschedule your appointment. We have a reminder policy where all scheduled patients are called 1-2 business days prior to their appointment to confirm that they will be attending. Please remember that these calls are merely a courtesy. You are solely responsible for keeping your child's appointments. We do not double book appointments. Therefore, if you do not call to cancel a scheduled appointment or call in a timely manner before your appointment, you create a vacancy in our schedule which would have been otherwise filled by another patient. We expect at least a 2 hour notice for canceling an appointment, although 24 hours is more helpful. Furthermore, our office may ask that you seek medical care elsewhere after 3 no-show appointments.
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Signature of patient (responsible party, if a minor)
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