Financial Responsibility
Tosa Pediatrics encourages you to familiarize yourself with your insurance benefits. Your insurance policy is a contract between you and your insurance company; therefore, you are ultimately responsible for payment of all charges. It is your responsibility to resolve disputes between you and your insurance company regarding deductibles, co-payments, coinsurance, covered charges, secondary insurance, or any other patient responsibilities indicated by your insurance carrier.
Individual/Group Insurance: While Tosa Pediatrics can assist in determining "in-network" status, it is ultimately your responsibility to confirm this determination. Not doing so may result in your responsibility for "out-of-network" charges. As a courtesy, Tosa Pediatrics agrees to file claims for services rendered with your insurance carrier. You understand, you are required to provide the most correct and updated information regarding insurance. You are responsible and expected to reimburse Tosa Pediatrics for the following:
1. Any co-payment as set by your insurance carrier at the time of service
2. Any unsatisfied deductible
3. Any amount your insurance carrier deems your responsibility
4. Any amount considered non-covered by your insurance carrier
5. Any charges related to termination of coverage
If Tosa Pediatrics has not received payment from your insurance carrier within 60 days from the date of service, you may be expected to settle any balance in full. You are responsible to confirm all charges are settled, whether by you are your insurance carrier.
You are accountable for responding to any request from the insurance company for further information. Not doing so will result in a claim denial and I will be responsible for payment.
Types of payment accepted: Tosa Pediatrics accepts cash, personal checks, Visa, MasterCard, Discover and American Express. There is a $30.00 service charge for returned checks.
No Insurance Coverage: Tosa Pediatrics offers a self-pay discount when payment is made within 30 days of services rendered. You are financially responsible for all charges incurred for services provided.
Liability: Services incurred resulting from injury or accident are considered your responsibility. It is your responsibility to ensure that Tosa Pediatrics is paid promptly regardless of pending disputed or litigated claims. Tosa Pediatrics is unable to file claims to a third- party insurance carrier.
Collections: Should there be any remaining balance on your account, you agree to pay for services rendered. If your account remains unpaid for a period of 60 days it may be outsourced to a third-party collection agency. Once your account has been put into collections your family may not receive services at Tosa Pediatrics until the balance is paid in full. Outside collections may result in your discharge from Tosa Pediatrics.
Insurance Authorization/Release: I authorize Tosa Pediatrics to release any and all information necessary concerning my diagnosis and treatment for the purpose of securing payment from my insurance company; and thereby authorize payment of the insurance benefits directly to Tosa Pediatrics for any and all services rendered.
I HAVE READ THE ABOVE INFORMATION AND AGREE TO BE FINANCIALLY RESPONSIBLE FOR SERVICES RENDERED BY TOSA PEDIATRICS.