Secondary Insurance Information

*If the patient is covered under two insurance plans, both companies must be aware of the other (coordination of benefits) for us to submit claims. Delays in coordination of benefits will result in full payment being required at the time of service.

Insurance cards must be presented to process claims. Only those presented on the date of service will be billed, if no insurance cards are presented you will be considered cash pash and be responsible for complete payment at the time of service.

I attest that all information completed above is correct. / hereby authorize and request Lawrence Pediatrics, PA, to provide medical evaluation and any treatment deemed necessary by the physician and/or nurse practitioner. / understand that, regardless of any insurance coverage, / am responsible for the payment of services. / authorize Lawrence Pediatrics, PA to release any medical billing or information to any of my insurance carriers to aid in processing claims. / also authorize direct payment to go to Lawrence Pediatrics, PA for any claims submitted by them. / further understand that / am expected to pay my co-pay or deductible portion at the time of service. If payment is not made at the time of service, / may be charged additional fees. / am responsible for knowing my insurance plan and its policies. / also acknowledge receipt and agree to adhere to all additional Lawrence Pediatrics, PA policies including but not limited to; Notice of Privacy Practices (HIPAA), Office Policies, Financial Policies, and Patient Rights and Responsibilities.

Designation of Health Representative for Patients 18 years and Older

This designation includes access to both written, electronic, and verbal information. This designation includes prior existing health information.

Designated Health Representative

*To file claims to your insurance, the subscriber must be listed above as a designated health representative. If you choose not to list the subscriber of your insurance, your account will be marked as "patient responsible for payment", and payment will be expected at the time of service.

I hereby authorize Lawrence Pediatrics, PA to use and release my individually identifiable health information as described above. I understand that this designation is voluntary. I understand that once this information is released, the information may no longer be protected by federal privacy regulations.

Patient Portal Consent for Adult Patients

Lawrence Pediatrics offers patients the ability to securely view their medical record, schedule well child exams, and communicate with our office via an on-line patient portal.

Using the patient portal, patients can:

• View / download their medical records
• View upcoming appointments and self schedule certain appointment types
• Send non-urgent messages to the office securely Request forms, referrals, medication refills, etc
• View billing statements and make account payments via InstaMed integration

Secure messaging can be a valuable tool but it does have certain risks. This form will explain those risks and the conditions for participation in the portal.

How the portal works: The portal uses encryption to keep unauthorized persons from reading any part of the transmission of information. Secure portal messages and health information can only be accessed by someone who knows the correct username and password to log onto the portal site.

Protecting your health information: Using a secure website prevents unauthorized parties from being able to access or read portal messages while they are in transmission. Keeping portal messages secure depends on you keeping your username and password secure. If you share your password with others, your information is not secure. If you think someone knows your password, you should change it. We do not share your email or other information with anyone else without your permission. Any parent or guardian you allow access will need their own login information.

Response time: We try to respond to messages and requests within 1 business day. If you do not receive a response within two business days, please call our office. DO NOT USE THE PORTAL FOR EMERGENT OR

All communications will be retained in your electronic chart. By signing the patient portal consent form you agree not to hold Lawrence Pediatrics or any of its staff liable for network infractions beyond our control.

By signing this form, you acknowledge that you will comply with the policies and procedures outlined in this document (please ask the receptionist for more information on the patient portal and login instructions You understand and accept the risks noted in this document regarding the use of the internet to access your health

Financial Policy for Adult patients

Thank you for choosing Lawrence Pediatrics. We are committed to providing the best care possible. This goal is best achieved by letting you know in advance of our financial policy, which is an agreement between you and the doctors of the practice. Your clear understanding of the financial policy agreement is important to our professional relationship. Please read this carefully and if you have questions, please do not hesitate to ask a member of our office staff.

Insurance

• All current insurance information must be presented at check-in. If you do not provide insurance information you are responsible for complete payment at the time of service.
• According to your insurance plan, you are responsible for any and all copayments, deductibles, and coinsurances. If your insurance plan does not cover a service, or if you have no insurance, the amount must be paid in full at time of service.
• Copayments are due at time of service. Copayments are a contractual obligation between you and your insurance company.
• Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered. It is your responsibility to understand your benefit plan, including but not limited to needs for referral or authorization for specialty care, preventative and vaccine coverage, laboratory tests, and other services that may be required.
• Please note that our providers follow accepted national guidelines when determining your charges. They must code based upon what services were provided and cannot take into account particular health plan benefits. They will not recode an office visit simply for your advantage.

Billing

• We provide the patient and/or the designated responsible party with an itemized statement each month when there is a balance due. We accept cash, checks, debit cards, MasterCard, Visa, American Express, and Discover. Additional itemized statements may be provided as requested and may incur an additional charge.
• We offer and encourage online bill payment utilizing InstaMed. You can find the link for this service on our website or your patient portal. There is no fee for paying your bill online.
• We will charge your account a $25.00 insufficient funds charge if your check is returned to us for insufficient funds. Should your check be returned due to insufficient funds, we reserve the right to decline future payment by check.
• Balances are due within 30 days of the date of service. Please call your insurance company for questions about the processing of your claim. Most problems can be settled quickly and easily, and your call will prevent any misunderstandings.
• If you are having difficulty paying your bill, please discuss the situation with the billing department immediately.
• Repeated late payments may result in deductibles and/or coinsurances being collected at time of service.
• We offer the option to leave a debit or credit card on file for future balances to be automatically charged after insurance processing. Card information is stored on an off-site, encrypted InstaMed server that is not visible to our office. This option requires an authorization form; please inquire at the front desk.

 

Office Policies for Adult patient

• Proof of all current insurance coverage and a form of government-issued photo identification must be presented.

• For the health and safety of our patients, we request that you bring no food or drink into the exam rooms.

• Due to HIPPA regulations, recording of any part of your examination or immunizations is prohibited.

• We require a minimum of 24 hours to fill out forms. We also require a minimum of 24 hours to refill medications. Refills can be requested through your patient portal or by calling the office. Forms can be sent to your patient portal or picked up in office. Photo identification is required to be presented to pick these up.

• If you are sick, please call our office to schedule an appointment. A receptionist will take a message and one of our nurses will return your call to assess your child's symptoms and schedule appropriately. Telehealth visits are available if appropriate.

• Lawrence Pediatrics utilizes Children's Mercy Nurse Triage Line for urgent after-hours phone calls that cannot wait until the next business day. Please be advised that there may be a $25 charge for this service billed directly to the patient.

• A missed (no show) appointment is defined as when you fail to show up for a scheduled appointment, show more than 15 minutes past your appointment time, or cancel without at least 24 hours' notice. Your appointment time is reserved for you and you will be charged for that time should you no show your appointment.

 

Patient Bill of Rights

Healing involves the coordination and cooperation of many caring specialties. You, the patient, are an important and essential part of the team working to provide you with the best care. Therefore, it is important that you are aware of your rights and responsibilities as described below:

Patient's Rights

• You have a right to considerate and respectful care.
• You have a right to confidentiality of all records and communications regarding your medical history and  health care to the extent provided by law.
• You have the right to request and receive information about your diagnosis and treatment from your
• You have a right to have a candid discussion about treatment options regardless of cost or benefit
• You have a right, upon request, to receive an itemized explanation of your bill, regardless of source of
• You have a right to reasonable safety in the clinic facility and environment.
• You have a right to the presence of an interpreter during any medical care provided.
• You have the right to receive information necessary to give Informed Consent prior to the beginning of any procedure and/or treatment, except for emergency situations.
• You have the right to refuse treatment from a health care provider and seek a second opinion at your
• You have the right to receive notifications by the health care provider in person or in writing when the decision is made to terminate the physician-patient relationship.
• You have the right to voice concerns about the service and care you receive and register complaints.

Patient's Responsibility

• You are responsible for being open and honest with us about your health history, including all medications (both prescription and over-the counter) you are taking.
• You are responsible for asking questions and making sure you understand the instructions given to you.
• You are responsible for keeping appointments and arriving on time.
• You are responsible for following the suggestions and advice prescribed in a course of treatment by your
• You are responsible for following the practice rules and regulations that apply to your conduct as a
• You are responsible for presenting an insurance identification card prior to receiving health care services, verify that the physician / healthcare facility is an in-network provider and pay any necessary co-payment and/or deductibles at the time you receive treatment and be aware of your benefit plan