Insurance: If you have insurance, we will provide insurance claim filing for the insurance plans with which we participate; however, if we do not accept your insurance plan or if a claim is denied or a balance is due, you are responsible for payment of the balance owed and we expect payment within 30 days from the date we notify you of such determination. It is your responsibility to pay any co-pay's, deductible, co- insurance or any other balance not paid for by the insurance or third-party payer within 30 days.
It is the responsibility of the patient/guardian to provide us with current insurance plan information prior to services rendered in order for accurate billing of services to be filed. You are also responsible for contacting your insurance company to make sure we are in network with your particular plan. It is important that you are familiar with the guidelines of your plan requirements regarding authorizations, deductibles, co- payments and other vital requirements.
In consideration of services rendered, you agree to transfer and assign to Celebration Pediatrics all rights, title and interest in any payment due to you or otherwise payable to you for services rendered.
Self-Pay: In consideration of the services rendered, you agree to pay Celebration Pediatrics in accordance with the regular rates and terms of service/costs for Celebration Pediatrics. Payment is due in full at the time services are rendered. You affirm that you are duly authorized as the patient or as patient's guardian/agent to execute this document and accept its terms.
Medicare/Medicaid: Patient's certification authorization to release information and payment request. You certify the information given to Celebration Pediatrics in applying for payment under Title XVIII/XIX of the Social security act is correct. You authorize any holder of medical or other information about you to release to Social Security Administration/Division of Family services or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. You further certify all insurance proceeds pertaining to treatment or services provided shall be assigned to Celebration Pediatrics.
Laboratory Charges: We collect and send specimens to a laboratory for processing. We are NOT responsible for laboratory charges. If you have any questions regarding the laboratory charges, you must call the laboratory listed on your bill.
Credit Cards: For your convenience, we will keep your credit card information on file to be used for balances on your account that are your responsibility (co-insurances, co-pays, and deductibles, not to exceed $150.00.
FMLA: There is a $25 fee for FMLA paperwork that is processed withing 7 business days. This fee is due PRIOR to any paperwork being faxed or picked up. There is a $50 fee for expedited FMLA paperwork.
Returned Check Fee: A $35.00 fee will be assessed to your account for any returned checks. No Show Policy: A $25.00 fee will be assessed to your account for any "NO SHOW" or CANCELLATION on a same day SICK appointment. All future appointments require a 24-hour cancellation notice PRIOR to the appointment, or the $25.00 fee will apply.
Tele-Care Call Policy: All calls after normal business hours requesting medical advice will be referred to the Arnold Palmer's Tele-Care Nurse Program. There is a $20.00 fee per call for this service. This fee is YOUR responsibility. This service is NOT covered by any insurance plan.
Colletions/Past Due Accounts: You understand and agree that all accounts must be brought current within 30 days of the service that was rendered. Should your account lapse past the 30 days your account will placed in a collections status and be transferred to our outside collection agency if payment in full or payment arrangements are not made.
You authorize Celebration Pediatrics and hereby give all of its affiliated entities, employees, agents and Independent Contractors permission to call you through the use of dialing equipment artificial voice or similar technology, even if you are charged for the call. You expressly agree that such automated calls may be made by Celebration Pediatrics and all of its ffiliates, contractors and agents. With such consent, you specifically waive any claim you may have against Celebration Pediatrics, its affiliates, contractors and/or agents for making such calls, including any claim under the Telephone Consumer Protection Act. You also expressly agree that this provision applies to the use of text messaging. You authorize Celebration Pediatrics, its affiliates, contractors and/or agents to use any cell phone or other telephone number to contact you for any purpose, including collection of an outstanding invoice at the number set forth below. If you have a change in address or telephone number, it is your responsibility to provide Celebration Pediatrics with your updated contact information.