Private Pay Policy 09232019
Private/Self Pay Release
*
I understand that El Paso Pediatric Associates, PA is accepting me as a Private Pay Patient, and I will be responsible for paying for any services I receive. I realize El Paso Pediatric Associates, PA may offer me a “Time of Service Discount”, but only if I pay the full amount of the Office Visit at the time of service. This “Time of Service Discount” will be discounted off of the Office Visit only. Additional charges may be billed to me after the day of service. These possible charges could included: labs, tests, screenings, x-rays, and other additional fees. Length and complexity of the visit can cause a higher charge after the patient sees the provider.
I understand El Paso Pediatric Associates, PA is not contracted with my insurance. My child can be seen, but as “Out Of Network”, and I will receive a bill for any unpaid service. I understand that El Paso Pediatric Associates, PA is accepting me as a Private Pay Patient, and I will be responsible for paying for any unpaid services I receive. I realize El Paso Pediatric Associates, PA may offer me a “Time of Service Discount”, but only if I pay the full amount of the Office Visit at the time of service. This “Time of Service Discount” will be discounted off of the basic office visit. Additional charges may be billed to me after the day of service. These possible charges could included: labs, tests, screenings, x-rays, and other additional fees. Length and complexity of the visit can cause a higher charge after the patient sees the provider.
“ We want to continue to offer great medical care for your child.”
Insurance
*
PCC Account #
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Parent Name
*
First Name
Last Name
Parent Signature
*
Clear
Today's Date
*
-
Month
-
Day
Year
Submit
Should be Empty: