After Hour Pediatrics Urgent Care Clinic
Note: For COVID_19 testing, the lab needs ONE cell phone and ONE email to send results. If you do not have a cell phone or an email,
write "landline" at the end of the "phone" text box SO we know to call you with results.
Contact for COVID Results:
I certify that the above information is true and I consent to any medical or surgical treatment rendered to the patient under the general or special instructions of the physician.
After Hour Pediatrics Urgent Care Clinic & Covid Care Consent to Treat & Notification of Policies
Consent to Treat: I certify that the information in the registration form is true and correct. I consent to any medical or surgical treatment rendered to the patient under the general or special instructions of the provider. For follow-up, such as lab results, X-ray reports or billing matters, I authorize AHP to notify me by phone, text or email. If AHP cannot reach me by phone, I authorize AHP to leave a message about the care of the patient.
Insurance: I authorize AHP to submit each visit and service to my insurance company on my behalf. I authorize the release of any medical or other information for the purpose of providing care or securing payment for services rendered. I authorize the payment of medical benefits directly to AHP. I agree that I am to pay any of these to AHP including but not limited to: co-insurance, copayment and/or deductibles and agree that I am to pay any of these non-covered charges at the time of service. I understand and agree that if my insurance company subsequently notifies AHP a rendered service is not a covered benefit for any reason on my insurance plan, I am to pay in full the amount not covered upon receipt of the patient statement ("EOB") and my credit card will be charged. If we are unable to verify your coverage, you will be asked to fill out an unable to confirm insurance form. We participate with many different plans and simply cannot know the provisions of every patient's policy. We strongly recommend that you make every effort to understand your insurance coverage and if necessary, contact your carrier prior to receiving services in order to verify your coverage levels (such as coverage for preventative care) and copay, deductible and coinsurance responsibilities. If we are not participating with your insurance, payment is due at the time of the visit. We do not submit claims to insurance plans we are not contracted with. It is your responsibility to respond to your insurance when they request information. We do not bill secondary insurance companies.
Credit Card Policy: AHP requires a credit card on file, which can be an HSA card or credit card for services that are not covered by your insurance, such as coinsurances and or your copayment or amounts applied to your deductible. I understand it is my responsibility to update my credit card on file. I understand that credit cards are stored electronically and are encrypted.
Missed Appointments: Please call us at least one day in advance to cancel or change your scheduled appointment. No call to our office equals a 'No Show' and we reserve the right to charge a $50 fee to cover some of the cost of that unfilled appointment
Health insurance non-payment: For the plans in which we participate, services that have not been paid for by your health insurance carrier within 90 days of claim submission will be billed to you (without an invoice charge) and become your responsibility to pay in full. Should your health insurance carrier later pay us for those services, we will immediately reimburse
Guarantor: The parent or guardian who signs the patient's paperwork is the party responsible for all charges and payments. Due to confidentiality rules we can only bill the person who signs the practice paperwork; therefore, if the person responsible for the medical bill changes, the new guarantor must complete a new set of paperwork. AHP is not a party in divorce or separation decrees or in child support arrangements. We bill one guarantor, at one address, and expect prompt payment.
Self-pay patients: If you do not have health insurance, if we are out-of-network for your insurance plan, or if you are receiving a non-covered service, payment at the time of the visit is required.
Acknowledgement of Vaccine Administration Policy: I understand that AHP will administer vaccines in accordance with the American Academy of Pediatrics Guidelines and the CDC. I also understand that I will be given information about these vaccines and the opportunity to discuss them prior to administration
After Hour Pediatrics Urgent Care & Covid Testing
For follow-up, such as lab results, X-Ray reports, or billing matters, I prefer AHP to notify me by phone or email at: