Healthykidspediatricspw - Financial Policy

Upon registration we will need the following information and items: insurance card (if you are a member of one of the plans that we participate with), the name, date of birth, address of the person who is the plan member, government-issued photo ID, address, patient's date of birth, contact phone numbers of both parents and/or all guardians.

Health Insurance: When scheduling each appointment, our team will verify your insurance information with you. Our office staff will verify your eligibility prior to or upon check-in at each appointment. Please make sure that you bring your card to every appointment. If your insurance changes, please notify us a soon as possible.We participate with many different plans and simply cannot know the provisions of every patient's policy. We do, however, 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 and copay, deductible and coinsurance responsibilities. If you are new to the practice and have an HMO plan., please make sure you have called your plan to select our practice/doctor as your PCP before the day of your visit. Otherwise your child cannot be seen.*

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Non-covered Services: Please note that there are some services that your insurance may not cover. These may include important tests which are considered pediatric standards of care such as Vision screens, Hearing screens, Developmental screens and in office lab tests. They may be part of your annual well-child visit. If your insurance rejects the claim for these screens or other services, we will bill you a discounted fee to ensure that you can afford the highest standards of pediatric care. We pride ourselves on providing only the highest quality of care for your child and do this by following American Academy of Pediatrics clinical guidelines and recommendations from other trusted evidence-based resources.*

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Balances, Deductibles and Copayments: It is our responsibility, as detailed by the terms of our contracts with health insurance companies that we participate with, to collect copayments at the time of service, and to bill you for any portion of your treatment that your health insurance carrier assigns as your responsibility. It is your responsibility to pay this portion of your bill. We are happy to set up a payment plan with you if you are unable to pay the balance in full at any time. Just make sure to set that up as soon as you receive the bill.*

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Returned Checks: If your payment by check is returned by the bank for insufficient funds, you will be required to pay a fee of $50. If more than one check is returned in any given period, we reserve the right to require all future payment via credit card or cash to prevent this situation from recurring.*

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Missed Appointments: Life happens and we understand that sometimes you cannot make your appointment. Please call us at least 24 hours in advance to cancel or change your appointment. No call to our office equals a "No Show" and if we can't fill your slot, we will need to charge you a $25 fee.*

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Self-pay-patients: If you do not have health insurance, payment is required at the time of the visit. If we are out-of-network for your particular insurer, payment is required at the time of visit. Our office can provide a claim form for you to submit to your out-of-network insurer.*

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Pending Insurance: If your child has lapsed insurance, no well visit will be scheduled until coverage becomes active. You will be required to pay for each sick visit at your self-pay rate. If you are able to get coverage retroactively, we will submit claims retroactively and refund your self-pay charges after claims are processed minus any copays, deductibles, co-insurance and/or personal responsibility. If your child is a newborn, please see our Newborn Insurance Policy.*

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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. Please inform us as soon as circumstances change.*

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I have read, fully understand, accept and agree to comply with all of the above policies. I agree to comply with any future amendments to the policies. I consent to the assignment of authorized health insurance benefits by my health insurer to Healthy Kids Pediatrics for any service furnished to my dependent or ward, and understand that failure to make payments timely may result in collection fees.

Patient's Name*

First NameLast Name

Parent/Guardian's Signature*

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Date*

Date

Parent/Guardian's Name(print)

First NameLast Name

Relationship to Patient

FINANCIAL POLICY