Authorization to treat: I consent to examination and treatment by the personnel at Etowah Pediatrics for my child or other dependents. This will remain in effect from this date forward unless “written” revocation of such

Authorization to release information and Assignment of Benefits: I hereby authorize the physician to release any information acquired in the course of my child’s treatment necessary to process insurance claims. Authorization to pay benefits to physician: I hereby authorize payment directly to the physician the surgical and/or medical benefits, if any, otherwise payable to me for services rendered, realizing that I am responsible for paying any co-payments, deductibles and other fees not covered by my insurance carrier.

Insurance Plans: I understand that it is my responsibility to confirm with my insurance company that the physician is currently under contract with my plan or be willing to be seen at “out of network” benefits. Any questions about medical, well baby/preventive care, labs/x-rays and immunization coverage should be directed to my insurance carrier prior to my visits. I agree to be responsible for all copays, deductibles and non-covered services determined by my insurance plan.

Payments: I guarantee that I will promptly pay all amounts that have been determined my responsibility by my insurance carrier once my insurance company returns patient responsibility. I understand that my health insurance contract is between my insurance company and myself. If my insurance does not pay for the services rendered by the practice doctors within 45 days, the practice may look to me for payment. The practice agrees to refund any overpayment that I have made on my account in the event that my insurance eventually pays. Any balance remaining after my health insurance pays, denies or deems non-covered under my plan will be my responsibility. If I have not paid my bill or have not arranged for a payment plan, the practice may ask for the assistance of an outside collection agency. If my account is turned over to a collection agency, I will be dismissed from the practice. The practice will try to work with me to avoid this.

Credit Card on File: We require all parents to leave a credit card number on file with our office. The card number will not be stored on our computer servers, rather encrypted off site at Navicure”s Secure Data Centers. You can be assured your information is secure. The card will be used as a convenient solution to paying your account balance. Card will be charged when insurance company returns patient responsibility.

Check In: Copays and past due balances are due at the time of check-in. Please come prepared to pay. Regardless of who brings the child in for patient services, payment is expected. Payment collection will not be delayed for any reason. If you do not have your copay or have not come prepared to pay past due balances, your appointment may be rescheduled for a later time so that you may meet your obligation. Please also bring your current insurance card with you at each visit. For all visits we will ask you to verify insurance and demographic information so that our records remain current.

Appointments & Late Arrivals: We ask you to arrive on time to your appointment. If you are more than 15 minutes late, you will be rescheduled for later that day if time permits. Or we may have to reschedule your appointment for another day. If more than 3 appointments are rescheduled due to tardiness, the practice reserves the right to dismiss the patient.

No Shows: Patients who do not keep their appointments deprive others of an opportunity to see their doctor. Please call us as soon as you know that you will not be able to keep an appointment. If more than 3 appointments are missed without notification, the practice reserves the right to dismiss the patient.

Minors: Unaccompanied minors must have a written authorization for medical treatment signed by the parent or guardian before treatment can be rendered. Parents must be available by telephone in the event that the physician needs to contact them. The responsibility for copays, deductibles and fees for non-covered services rests with the accompanying adult.

Service Fees and Indemnification: Your account will be charged $30 for NSF/Returned checks. Interest will be charged on your account at either 12% per annum or the maximum allowable statutory rate. For payment of said accounts for services, I hereby waive all claims of exemption under the State of Alabama and agree to pay all costs of collection including court costs and reasonable attorney fees. Moreover I agree that any court action initiated against me is subject to the sole and exclusive jurisdiction of the district or circuit courts of Etowah County, Alabama. I also agree to indemnify and hold harmless Etowah Pediatrics, P.C., and its owners, officers and employees, for any claims, lawsuits, causes of action or damages of any nature caused by my breach of this Policy, other Etowah Pediatrics, P.C., policies, and for any claims made by my insurance carrier regarding my account.

Notice of Office Policies: I am aware of the policies of Etowah Pediatrics (No-show, Walk-in, Payment, dismissal due to errant behavior, transfer, etc.) I understand that I may view these policies on the website www.etowahpediatrics.com, or ask for an explanation of the policies while in the office.

Authorization to release information: I hereby authorize Etowah Pediatrics, P.C. to send immunization, medication records and/or routine physical forms to my child’s school or other physicians at my verbal request.

Cell Phone: You agree, in order for us to service your account or to collect monies you may owe, Etowah Pediatrics and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing devices, as applicable. I/we have read this disclosure and agree that Etowah Pediatrics, its employees and/or agents may contact me/us as described above.

Notice of Privacy Practices Acknowledgement: I am aware of the Etowah Pediatrics Notice of Privacy Practices. I am also aware that I may obtain a copy of the notice simply by asking the front office staff. And, I am also aware that I may obtain information by asking any questions that I may have.

Notice of Nondiscrimination: Etowah Pediatrics complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

I have read, understood and agree to the above financial and office policies. I understand that Non-compliance with these policies may result in transfer of care to another practice. Please add patients, more spaces will fill as you fill in the provided space.