By virtue of my signature set forth below, I hereby request that my provider and All-Star Pediatrics reduce their usual and customary charges in order to allow my child to receive care required by his/her current health care condition.
I recognize and acknowledge that this Agreement to reduce usual and customary charges is undertaken for my benefit, that this is dependent on my financial status as of the date of this Agreement, and that it will result in a fee arrangement distinct from the one usually in place for the services in question. I understand and agree that the arrangement represents a confidential agreement for my sole and exclusive benefit. The charges listed below are the result of a pre-pay discount, and this arrangement is only available and due at the time of service.
This agreement is only available because: I have NO insurance coverage for this child on this date OR because I have insurance not contracted with All-Star Pediatrics, and cannot afford the usual and customary charges for these services.
All treatments done in the office at the time of the visit are included in the charges listed below (i.e. strep testing, breathing treatments). If any outside testing is needed (i.e. x-rays or send-out lab work) – I understand that I will receive a separate bill from the appropriate facility.
NOTE: Children WITHOUT insurance can receive the Vaccines-For-Children program vaccines, with charges below. Those with insurance other than AHCCCS cannot get them at our office.