EPPA Financial Policy and Consent-2019

We are committed to providing your family with the best possible pediatric care. Your signature at the end of this document will indicate that you have read, understand and agree to the policies outlined below and that you will be financially responsible for any and all charges not paid by your insurance.

• Please present your current health insurance card at each office visit.
• Our office will bill validated Primary Insurance as a courtesy. You must pay for any patient responsibility.
• If you have No Insurance then payment in full is required at the time of service.
• Know your insurance and REMEMBER: Non-covered services such as vaccines can be VERY EXPENSIVE

• Co-pays, co-insurances, and deductibles must be paid at the time of service. 

• We mail statements on a weekly basis. Payment is due upon receipt of your statement.
• Additional Fees include: Nurse Forms, Same day Referrals, Same day Prescriptions, Controlled Substance Prescriptions, After-Hours Fee, and other required forms.

• We require a valid credit card be kept on file to cover any past due balance. Please see the next page.
• Past Due accounts will be “Flagged” as “Past Due” and could delay or prevent scheduling an appointment untilpayment arrangements have been made.

• The charge for a non-sufficient funds (NSF) check is $35. You must pay in full for the NSF check and NSF fee within 10 days of notice. If payment is not received by the due date, we will forward the returned check to the District Attorney’soffice. It is a felony to knowingly write a bad check. For the next 12 months, cash or equivalent payment at the time ofservice is required

• When an account remains unpaid after 90 days we reserve the option to refer the account to an outside collectionagency. If your account is sent to an outside collection agency, there will be a 40% surcharge added to your balance. EPPA reserves the right to reschedule or deny future appointments for delinquent accounts. If your account is sent to a collection agency you may be asked to find another provider.

• We require a 24-hour notice to cancel or reschedule an appointment. For appointments scheduled within 24 hours of theappointment time, a 2-hour notice is required. If you arrive 15 minutes late to your appointment, you have missedyour appointment; therefore, a late cancellation fee could be charged, whether you are seen then or not.
• Failure to give proper notice for cancellation or reschedule will result in:
  • A $25.00 charge for “Late Cancellations”, per child
  • A $25.00 charge for the “Missed Appointments”, per child
  • Your family could be subject to dismissal for “Chronic Missed appointments”.

*I acknowledge and understand the office policies and procedures explained above and have received a copy. I hereby authorize my insurance companyto pay El Paso Pediatric Associates, PA directly. A copy of this authorization can be considered an original for insurance purposes.

*I do hereby consent to and authorize the performance of all examinations, treatments, and medical services by El Paso Pediatric Associates, PA and theirstaff, which may be deemed advisable. My signature on this document indicates that I have read, understand and agree to the policies outlined in this document

El Paso Pediatric Associates, PA (EPPA) requires that a valid credit card be kept on file.

This policy is designed to:

• Help you avoid all billing related fees
• Streamline the billing process in our office and eliminate the expenses related to handling overdueaccounts
• Focus our time and energy on your children and their medical care

The card information is stored electronically in an encrypted form and cannot be viewed by our office staff.

Your signature will authorize the card to be used 14 days after your balance becomes due.

How the policy works

1. At the time of registration or check-in, you will be asked for your credit card information to be electronicallystored in encrypted form in our computer. Only the last four digits are visible to our staff.
2. As before, we will bill your insurance carrier as a courtesy for all charges related to the visit.
3. When we receive an explanation of benefits (EOB) from your insurance, we will send you a statement thefollowing week. If we have not received payment within 14 days, we will charge the credit card on file for thebalance due (on statement). Please call 1-866-371-6118 Ext 124 to make payment arrangements if necessary.
4. If EPPA attempts to use your card and it is declined or has expired, EPPA will send you a new statement witha note asking for current credit card information.

Please remember that this policy does not restrict your right to appeal any charge made to your credit card. Should you feel that we have charged your card in error, you may contact our billing office. If a mistake has been made we will reverse the charges.

I have reviewed a copy of El Paso Pediatric Associates, PA billing policy and agree to provide my credit card information to El Paso Pediatric Associates, PA for the sole purpose of payment for my child(ren)’s medical care.