I hereby authorize GATEWAY PEDIATRICS, LLC to leave voice and/or text messages regarding testing results and scheduled appointments to the cell phone number(s) listed above (Standard SMS Rates may apply)
I authorize GATEWAY PEDIATRICS, LLC, to discuss medical treatment and billing with the following authorized adult(s) (e.g: Parents, Grandparents, Siblings, Step-Parents, etc):
THIS POLICY IS FOR PATIENTS THAT ARE 18 YEARS OLD AND OLDER.
I understand, accept, and acknowledge the following terms:
COLLECTION POLICY & AGREEMENTWhen payment is not made as agreed, account balances inclusive of all charges and reasonable collection costs agreed to herein may be sent to outside collection firms for legal collection action. It is understood and agreed to by the undersigned patient that any account, which becomes more than ninety (90) days delinquent may be turned over to our attorney for initiating litigation to collect the outstanding invoice. If the undersigned fail(s) to make any payments due hereunder, Gateway Pediatrics, LLC may at any time thereafter, without notice or demand, declare the entire unpaid balance of the account to be immediately due and payable. The undersigned promise(s) to pay all cost of collection equal to thirty-five (35%), including, but not limited to, court costs, attorneys’ fees equal to fifteen percent (15%) of any amount due and owing to Gateway Pediatrics, LLC, and any other collection fees which are incurred by or on behalf of Gateway Pediatrics, LLC in enforcing payment after default. If court action is necessary to enforce payment hereunder, the venue for any such court action shall be in Wicomico County, Maryland unless Gateway Pediatrics, LLC elects otherwise. The undersigned waives any objection to venue or jurisdiction. A copy of this Payment Agreement shall be as valid as the original. Gateway Pediatrics, LLC will discharge (with 30 days’ notice) the entire family of a guarantor sent to collections. Payment of the unpaid balance and cost of collection must be made in order for you to return as a patient of our practice.
I have read and understand the financial policy of the practice and I agree to be bound by its terms for payment of all professional fees. By signing this statement, you and your designated parties have agreed that the insurance information you have provided to GATEWAY PEDIATRICS, LLC is the only health insurance coverage for the patient. I understand and agree that such terms may be amended by the practice. The patient/parent is ultimately responsible for all professional fees.