ALL PAYMENTS ARE DUE AT TIME OF SERVICE
COPAYMENT: Payment is required at time of service unless other arrangements have been made in advance. This includes applicable coinsurance and copayments for participating insurance companies.
RETURNED CHECK FEE: Hamilton Mill Pediatrics accepts cash, in-state personal checks, VISA, Mastercard. There is a $25.00 service charge for any returned checks.
BILLING: A $5.00 service fee will be added to any co-payment that is not paid before the last day of the month. An additional $5 fee will be charged EACH month that a co-payment balance is not received.
OUTSTANDING BALANCES: Patients with an outstanding balance of 60 days overdue must make at least a partial payment or payment arrangement prior to scheduling any further appointments.
INSURANCE: We bill participating insurances. You are expecting to pay your deductible and copayments at the time of service. If we have not received payment from your insurance company within 90 days from the date of service, you will be expected to pay the balance in full.
MISSED APPOINTMENTS/LATE CANCELLATIONS: Missed appointments cause a delay in care to other patients. Any cancellation/late show without at least a 2 hour notice will be subject to a $30.00 fee to be applied to the family account for each missed/late appointment. We respectfully ask that all patients arrive to their appointments on time or early; however, we understand that occasionally people will run behind due to circumstances beyond their control. If you see that you will be running late for your child’s appointment, we ask that you call and notify the office. Excessive abuse of this policy is subject to discharge from practice. **Please note we reserve the right to dismiss any new patients who no-show for their initial visit**
MEDICAL RECORDS REQUEST: There is a $15.00 charge for the copying and mailing/faxing of medical records for all patients.
Consent to Use and Disclosure of Protected Health Information
I hereby give consent for Samantha Ball, DO, LLC doing business as Hamilton Mill Pediatrics, to use and disclose protected health information (PHI) about me/the patient to carry out treatment, payment, and healthcare operations (TPO).
With this consent, Samantha Ball, DO, LLC doing business as Hamilton Mill Pediatrics may mail to my home or alternative location as well as email or text any items that assist the practice in carrying out TPO, such as appointment reminders, lab results, and patient statements marked personal/confidential.
I have the right to request that Samantha Ball DO, LLC restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does it is bound by this agreement.