GRAHAM PEDIATRICS OF WOODSTOCK
105 Mirramont Lake Drive, Woodstock. Ga 30189
Phone 770-485-9670, Fax 866-698-9350, www. grahampediatrics.com
Financial Responsibility Form
Graham Pediatrics of Woodstock (GPOW) partners with you to take care of your child. We would like to take the time to clarify our expectations of your responsibilities, please read and sign, acknowledging your understanding of our financial policies.
For each visit please bring your:
- Current insurance card (without current insurance information there is no way for us to verify eligibility and file your claim/visit, so, when you don’t provide us with this important information, you will be considered as self-pay on the day of service). Please remember to bring a valid photo ID.
- Copays or Deductibles: Patients are responsible for insurance copays or deductibles at the time of service. We will collect payment from the attending parent/guardian.
Private Insurance (Newborns/Patients)
- Please provide our office with the policy holder information: name, date of birth, address, phone number, and a copy of the insurance card in order for us to verify eligibility at the time of service.
- Note: If you apply for a private insurance, please note that most private insurance plans give 30 days to activate coverage for your baby, please make sure that all your paperwork has been received by your insurer carrier, so that coverage will be in place before your baby’s 1st month checkup to avoid claims being denied by the insurance and you paying out of pocket for current and previous services.
Medicaid Insurance (Newborns/ Patients)
- If you apply to Medicaid and do not have a Medicaid ID number or card at the time of your visit, please bring “a printed copy of proof that you have applied” otherwise you will be financially responsible for the visit at the time of service. Also, as a courtesy we allow 6 weeks for your child to obtain a Medicaid ID number, after that time, you are financially responsible for present and previous visits.
- If we are not in-network with your insurance or your child does not have insurance, you will be considered selfpaid and the balance must be paid in full at the time of visit.
Coinsurance: As a courtesy we bill co-insurance, after your insurance has processed your claim.
Coordination of benefits: If you have two health insurances, it is your responsibility for you to call each insurance and do “coordination of benefits” this means that each insurance knows that you have another insurance. Please make sure that we are in-network with both insurances, otherwise your claims will be denied, and you will be financially responsible for any balance generated from these denials.
Combined visits: If you are scheduled for a well child exam, and other health concerns are brought up that would typically require a sick visit, your insurance company may consider these two separate visits and generate a statement for your copay and other charges accordingly.
- Your insurance contract is between you and your insurance carrier not GPOW. You are financially responsible for all charges not paid by your insurance carrier, and you will be sent statements regarding your balance.
- Patients must know their insurance benefits and what type of visits, vaccines, well check, labs or other procedures are included and covered by their insurance.
- The parent/guardian whose names are listed in the Patient Registration Form are responsible for patient’s outstanding balances.
- We will send you several statements for outstanding balances. For balances that remain unpaid after 60 days, you’ll need to call the office and make the necessary financial arrangements. Failure to do so, will result in your account sent to a collection agency. We will require the collection agency balance to be paid via cash, debit or credit card prior to any future visits. You may be asked to be financially responsible for the visit at the time of the service and will be refunded any payments made by your insurance company. Any family whose account is forwarded to a collection agency may be dismissed from the practice.
- It is your responsibility to clear your balance upon your due date on your bill or if you have a visit before that, whichever comes first. We accept Visa, Master Card, American Express, Discover for your convenience.
By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure, understand your responsibilities, and agree to these terms.