We thank you for your interest in joining the Friendly Hills Pediatrics family! We are an independent, private, pediatric medical facility.
Our mission is to provide superior access to high-quality and compassionate medical care when families need it most.
To receive the perks of this model of care, a membership to our practice is essential to support these services.
Please note that, as with other medical practices who accept health insurance, when your child receives care, it is expected that you pay for the portion that you are responsible for, at the time of the visit. As a courtesy to you, we will bill the patent's medical insurance for the office visit.
We hope you feel that our practice is a good fit for your family. We look forward to building a long-lasting relationship with you and your child.
The following are the annual membership dues:
$125 for a child who is less than 6 years old
$100 for a child who is 6 years old and older
The maximum yearly dues for a family will be $300.
The dues are used to support the specialized level of care and personalized, positive experience for your child. In the long run, your child’s health will benefit from easy, comforting medical visits.
Please note that you may only pay for your annual Member Dues via cash, credit card, or debit card, and dues are collected at the time of registration. The annual member dues are a non-contractual fee and are non-refundable.
Patients with Medicaid will have a courtesy 25% discount on member dues.
We require that you bring your child's pertinent medical record to your child's first appointment in our office or have the records sent to us before the first scheduled appointment. Medical records include your child's most recent wellness check, immunizations and any specialist record(s).
We are happy to assist you with requesting records from your child's former pediatrician's office, or from a specialist.
If the records need extensive review, as determined by our staff and/or your child's new pediatrician, an appointment will necessary for this review of medical records. The appointment may be done as a telemedicine, when appropriate. This policy applies for any future specialty referrals, as deemed necessary by our office.
The purpose of this type of appointment is to better understand your child's health and to assist families who have questions not answered by their specialist(s). Any fees associated with that visit will apply, as per usual. We hope that you understand and come to appreciate the purpose of this policy.
We participate with most insurance plans. Each insurance policy is different. Therefore, it is important to contact your insurance company if you have any questions regarding your benefits and know what your payment obligations will be at the time of service.
Depending on your insurance policy, a copayment and/or deductible may be required at the time of service. These payments are expected to be made at the time of service. We accept cash, credit cards, Health Savings Account (HSA) cards for payment.
Please note that the copayment is a contractual requirement from your insurance company and cannot be written off by our clinic. If you participate in a High Deductible Health Plan (HDHP) and have not yet paid your deductible in full, it is likely that any non-preventive services will require payment at the time the services are rendered. Please ensure that if you are unable to bring your child in yourself, whoever brings the child in is prepared to make all payments.
We require notice of at least one business day for all cancellations. Failure to notify the clinic within one business day will result in a no-show fee of $40. Repeated no-shows will result in the family being advised to transfer care out of the practice.
Friendly Hills Pediatrics does not get involved in disputes between divorced, separated, or custodial parenting arrangements regarding financial responsibility for their child's medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree, custodial or other arrangement places that obligation on your former spouse or the child's other parent. We will be happy to provide receipts for paid medical bills for you, as requested.
At Friendly Hills Pediatrics, we offer Direct Primary Care (DPC), which allows our medical office to work directly with you! A flat monthly fee covers the membership, which provides all the care in the office, and we never bill your insurance plan. You will never pay a co-pay or co-insurance for an office visit. Direct primary care allows doctors to provide more accessible, personalized care for their patients, which results in more satisfied patients, families, and medical staff. Scheduling appointments is easy via the SpruceHealth app and your child can be seen on the same day or the next for acute visits.
Health insurance is complex and can get in the way of good medical care. DPC is the perfect option for routine medical care and it allows for building a special relationship with your doctor. When medical offices rely on health insurance companies for reimbursement, it forces medical offices to see large amounts of patients. As a result, families are often rushed through their appointments. Not to mention the high out-of-pocket expenses and network limitations. This is why DPC is a wonderful option for all families.
Ask us for details!
We are committed to making our billing process as simple and easy as possible. We require that all members provide a credit card on file with our office. The credit card is scanned into CardConnect, a secure Merchant Services site. We never store any credit card information elsewhere.
For security reasons, only the last four digits will be visible to our staff. Credit cards on file can be used to pay copays and other charges (such as toward the deductible or for non-covered services).
Once processing the visit with your insurance, you may owe part of the patient responsibility fee. If we do not receive payment for the amount due on your statement within 14 days, we will run the credit card on file for the full amount owed.
Your account becomes delinquent if not paid within 30 days after the date of the original statement. The unpaid balance will be subject to a finance charge of 1.5% (18% APR) or $35, whichever is greater. Further delinquency will be subject to collections with additional finance fees and your care will be transferred to another office.
We pride ourselves on providing only the highest quality care for your child and do this by following many of the American Academy of Pediatrics clinical guidelines and other trusted sources for evidenced-based clinical outcome information.
However, insurers rarely keep pace with guidelines, or want to cover services related to meeting these clinical recommendations. In fact, insurance company rules and policies change all the time. As prompt and appropriate treatment of your child is of primary importance to us, we ask that you sign a ‘waiver’ giving us permission to perform screenings, tests and non-covered services as we, your trusted providers of care, deem necessary.
Following is a list of the most frequently provided services for which we request a signed waiver and that you can use to determine coverage with your insurer.
- Visual Acuity Testing. This is a screening performed with the use of a Snellen eye chart used to measure visual acuity on older children.
- Photoscreening. This is an important test for early detection of eye and vision problems in infants and young children (age 1 to 4 years old). Amblyopia (or ‘lazy eye’) occurs when the brain does not receive proper images from the eye. If it is not diagnosed in early childhood, there may be a permanent loss of vision in the affected eye.
As we consider these to be important tests for your child, and will routinely perform them at annual well visits. If your insurer does not cover the charge, we will significantly discount the amount. For Visual Acuity tests the discounted price is only $10.00, and for the photoscreener test, the discounted price is $15.00.
In-office lab tests
Often, patients want to know as soon as possible if their child has the flu, strep, etc. We can effectively and efficiently determine that by performing in-office testing. Many insurers do not pay for in-office testing because they have contracts with external labs to provide these services. However, sending tests out to external labs results in waiting days for results that we can provide to you much more quickly (in some cases, within minutes or overnight). We believe it is important to treat your child as quickly as possible, and therefore offer these services in-office.
In-office labs and fees include:
In-office TestReduced PriceRSV Test$25.00Rapid Flu $25.00Rapid Strep $10.00Urinalysis$10.00Pregnancy Test$10.00
In addition to screenings and lab test, we also offer ear piercing which is not a covered service by your insurance company. We charge $100.00 which includes a pair of medical-grade plastic earrings.
Please sign the following waiver indicating that you are aware that these charges may apply in the event that your insurance company does not cover these services.
Waiver Form Acknowledgement of Receipt
I acknowledge receipt of the Waiver List and have been informed of, and hereby attest that I fully understand my financial responsibility for any balance resulting from non-covered services, or services not covered in-office, by my insurer. I agree to pay the amount of the charge as stated herein, in the event that my insurer does pay for these services.
Sign here indicating your agreement to the waiver for non-covered services. Signature First Name Last Name
I, First Name Last Name , hereby give consent to Friendly Hills Pediatrics to perform any radiology or lab testing, examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care as deemed advisable by a licensed physician, nurse practitioner or physician assistant, as well as any assistant on the staff of Friendly HillsI understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required.This consent is given to any and all such diagnoses, treatments and hospital care which a licensed physician at Friendly Hills Pediatrics recommends.This authorization will remain in effect for 6 months from today's date or until revoked in writing by the parent or legal guardian.Signature Date Please specify relationship to minor:Parent with legal custody Guardian with legal custody
All professional services rendered are charged to the patient and are due at the time of service, unless insurance coverage is verified and Friendly Hills Pediatrics is a participating provider. Necessary forms will be completed to file for insurance carrier payments.
Assignment of Benefits
I hereby assign all medical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including private insurance and any other health/medical plan, to issue payment check(s) directly to Friendly Hills Pediatrics for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by
Authorization to Release Information
I hereby authorize Friendly Hills Pediatrics to: (1) release any information necessary to insurance carriers regarding myself and/or my dependent's illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.
I have requested medical services from Friendly Hills Pediatrics on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.
I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges (copay, coinsurance and/or deductible) incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
I have read and understand all the above statements and agree to uphold the terms and conditions of the above policies of Friendly Hills Pediatrics.
Welcome to Friendly Hills Pediatrics!
We are looking forward to being your pediatric medical home.