OFFICE AND FINANCIAL POLICIES

The policies set forth on this form are for the mutual benefit of our patients and our office. Failure to comply with these policies may result in violation of our practice policies and rules which may lead to ending our patient-provider relationship.

Account Responsibility: The parent who registers a child for treatment agree to accept financial responsibility for any unpaid services within 14 days of receipt of billing statement. We will send claims to your insurance carrier. If the claim is denied or not paid you are responsible to pay balance within 14 days of notification.
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Insurance Claims: Your insurance is a contract between you and your insurance company. It is your responsibility to determine what benefits, in network services and type of coverage your policy provides. In order to bill your insurance properly and in a timely manner we ask that you update our office if you have changed your insurance plan before your child is seen by a doctor. Failure to update insurance prior to your child being seen may result in you being responsible for payment. Our office only processes claims through your primary insurance, we do not bill secondary plans including Medicaid. All commercial insurance plans are primary to Medicaid.
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Insurance Claims: Your insurance is a contract between you and your insurance company. It is your responsibility to determine what benefits, in network services and type of coverage your policy provides. In order to bill your insurance properly and in a timely manner we ask that you update our office if you have changed your insurance plan before your child is seen by a doctor. Failure to update insurance prior to your child being seen may result in you being responsible for payment. Our office only processes claims through your primary insurance, we do not bill secondary plans including Medicaid. All commercial insurance plans are primary to Medicaid.
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Professional Services Rendered: If your child is seen for a Well/Preventive Visit and another condition/s is/are treated, your insurance will be billed for a Sick Visit as well, and your insurance company may bill back a co-payment and may be subject to your deductible. We may change the Wellness Visit to a Sick Visit and your insurance company may also bill back a co-payment and may also be subject to your deductible as well. The office can only bill and file a claim for your child's visit with the diagnosis that was encountered and documented in the medical record. Thus, to ask this office to change a diagnosis solely for the purpose of securing reimbursement from an insurance carrier is fraudulent and will not be done under any circumstance.
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Payment will be expected at the time of service when: + We are not contracted with insurance plan. + We are unable to verify coverage. + There is an outstanding balance. There is no insurance coverage.
New insurance card is not available to us. All cash accounts are expected to pay in full.
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Divorce, separation and/or custody agreements: Our office ultimately holds both parents accountable for any balances incurred by their child/ren. A divorce decree is a document that involves both parents and the courts. Although your divorce decree may state that an ex-partner or ex-spouse is responsible for medical bills, our office has no authority to enforce compliance or act as a mediator between parties. If there are any outstanding balances on your child/ren account it must be paid by whichever parent is present with the child. If the parent is not prepared to pay the balance the appointment will be cancelled.
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Copayments: You are expected to pay your co-payment each time your child is seen in our office. No exceptions! Your appointment may be rescheduled if you are not prepared to pay your copayment.
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Appointment Policies and "No-Show". "Late-Cancel" and other fees are as follows: You agree to keep appointments made on the same day and to pay $50 if the appointment is missed. You agree to notify the office 24 hours prior to your Well Child appointments if you want to cancel and pay $120 if the appointment is missed or cancelled late. Our office reserves the right to dismiss patients from our office for repeated missed appointments as well as non compliance to medical recommendations (treatments and referrals Other fees: Returned check fee: $35 Miscellaneous letters: $15.00 Letters to utilities: N/A - we do not write letters to utilities Copies of immunization: One free copy per year, subsequent copies: $2.00 Sports/School/Camp Physical forms: One free copy every year, additional copies $15.00 each FMLA forms, Social Security or Immigration forms: $25.00
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Collections: All accounts with an outstanding balance for over 90 days is subject to collections regardless of the dollar amount owed. If you have multiple payment arrangements that have been broken your account is at risk of collection regardless of the amount owed. If an account is sent to the collection agency, we consider both parents responsible, even in a divorce situation both parent's information will be submitted. A 40% collection assessment fee will be applied to any account that is referred to collections and needs to be paid if you wish to return to our office.
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Disruptive/abusive behaviors in the office will not be tolerated and may lead to the immediate termination of patient-provider relationship. Disruptive and abusive behaviors include but are not limited to the following: 1. Verbal abuse (Profanities, demeaning, disrespectful, derogatory, extremely loud or discriminatory language) 2. Physical abuse or threats of physical abuse such as throwing things or threatening violence towards the staff 3. Sexual comments/sexual harassment 4. Non-compliance with office policies 5. Illegal acts or behaviors that are dangerous, unethical or dishonest
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Patient Accompaniment: It is required by law that a child be accompanied by their parent/s, legal guardian or an adult representative with a written consent from the patient's parent/guardian to accompany and consent for the child's check-up, evaluation and/or treatment and their corresponding fees EXCEPT for immunizations for which parents or guardian have to physically sign a consent for administration of immunizations.
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Acknowledgement and Agree to Comply: Please be advised that these stated policies are subjected to change and all changes will be made available on our website and posted in our office reception area. These changes will become effective at the time they are posted.
By signing below you are consenting to accept and abide by any posted changes as well.
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