*Limited access for patients 13-17 years old.

Charges for new patients are due and payable at the time of the first visit, unless a valid insurance card is presented. 

I authorize my insurance benefits to be paid directly to Richmond Pediatrics. I hereby authorize the physician or insurance company to release my information necessary to secure payment.

Please check the box if any of the following conditions apply to any relatives.

Responsible Party
You are financially responsible for paying for services that are provided to you by our providers. If the patient is a child, the responsible party will be the biological parent and/or the assigned representative authorized to seek medical care for the child and is the party that brings the child in for services.

Understanding Your Benefits
Please familiarize yourself with your insurance benefits and verify that the provider you are seeing is part of the preferred provider network. Your health plan mandates that you are financially responsible for payment of all copays, deductibles, and non-covered services; Richmond Pediatrics is contractually obligated to collect them. We do not verify
insurance benefits, which is why we highly recommend that you contact your insurance company and familiarize yourself with your policy’s benefits.

Understanding Our Charges
Patients will be charged for each service that is performed during the course of an office visit. Included in the base charge for an office visit is a discussion about the nature of the illness, an examination of the patient, medical decision making, development of a treatment plan and discussion with the patient about the plan. Other activities (procedures) are billed in addition to the charge for the examination. These charges may include, but are not limited to, sutures, wart removal, vision & hearing tests, removing wax or foreign bodies from ears or nose, lab tests, administration of immunizations and other additional services. Please note that if during a well-child examination any additional concerns are raised or illnesses are treated there may be additional charges associated with this visit.

After Hours Care
If a medical problem arises after routine office hours, and you would like advice from the Seattle Children's Hospital Nurse Triage Team, call our regular office phone number (206-546-2421) and our answering service will connect you. Please note that there is an $18 charge for each call to the nurse triage team, and you will be responsible for the bill, as
this service is not covered by insurance. You may instead contact your insurance company’s own after hours consulting nurse line, as this service may be offered by them free of charge. This nurse line telephone number is often found on your insurance card.

Co-Payments are due at the time you check in for your appointment.

Billing Statements
You will receive a billing statement from us after the insurance has processed your claim if there is any patient balance remaining. Your charges will be listed along with any payments received from your insurance company. This listing will correspond to the explanation of benefits (EOB) that you will receive from your insurance company. You will receive a statement from our office every 30 days until the balance is paid in full.

Rebilling Fee
All balances are due and payable upon receipt of your statement. If your account becomes 30 days past due, a $10 rebilling fee will be added to your account and will continue to be added once every 30 days until your balance is paid or payment arrangements are made with our billing department. If you are unable to pay the entire amount due, please contact our billing department at 206-546-2421 ext. 303 to set up payment arrangements.

Returned Check Fee of $30 will be charged to your account for all returned checks.

Payment Options
Richmond Pediatrics accepts cash, checks, money orders, VISA, MasterCard, Discover, & American Express. Credit card payments can be made in person, by mail, or over the phone by calling 206-546-2421, ext. 303.

Collections
In the event that your account remains unpaid for more than 90 days and no one has made any attempt to make a payment, your account will be sent to an outside collection agency.

Missed Appointments or Late Cancellations

Richmond Pediatrics will charge and dismiss families for:
1. Not showing up for scheduled appointments
2. Late cancellations: Cancelling well child or consult appointments with less than 24 hours’ notice (one full business day), or cancelling illness appointments with less than 4 business hours’ notice

What will happen if you miss an appointment or cancel your appointment late:
1st Occurrence - No charge, a reminder letter of our policy will be sent.
2nd Occurrence - $25 charge for an illness visit, $50 charge for physicals and consultation visits.
3rd Occurrence - Charges as above, and a warning letter notifying you of dismissal if there is another no show or late cancellation.
4th Occurrence - Charges as above; dismissal from practice.

*Please note any alteration and or notes made on this form will not be valid without prior approval from our billing department and noted below with signature of authorized billing department personnel. Since our Financial Policy is subject to change without notice, you may view our current financial policy on our website at www.richmond-pediatrics.com.

Richmond Pediatrics has a responsibility to protect the privacy of your health care information and to provide a Notice of Privacy Practices that describes how your health care information may be used and disclosed, how you can access your health care information, and whom to contact if you have questions, concerns, or complaints. 

We may change the Notice of Privacy Practices at any time, and you may contact our office manager at 206.546.2421 to obtain a current copy of the Notice of Privacy Practices or to ask questions. 

*Please Note: The private insurance category includes private health plans and children in state sponsored health plans (e.g. Health Care Authority Basic Health Plan (BCP), and DSHS CHIPRA (formerly SCHIP), CHP or other non-Medicaid DSHS health plans.