Financial Packet 2023 (OLD)

TOTAL Number of Children at Practice:*
Please include children without appointments
1) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
1) Age
2) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
2) Age
3) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
3) Age
4) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
4) Age
5) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
5) Age
6) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
6) Age
7) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
7) Age
8) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
8) Age
9) Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
9) Age

Patient Contact Information

(Will only be requested for patients aged 16 years and above)
As your child is beginning to transition into adulthood, we want to help prepare them for assuming responsibility over their personal healthcare management. In this regard, we kindly request the contact details of all patients aged 16 and above. This will enable us to create portal accounts for them, granting access to their individual medical records. Our intention is to promote proactive engagement among our patients in acquainting themselves with the functionalities of the patient portal, engaging in correspondence with their doctors, and fostering a sense of agency in matters pertaining to their well-being.
{1Patient}'s Phone Number*
Please enter a valid phone number.
{1Patient}'s Email*
example@example.com
{2Patient}'s Phone Number*
Please enter a valid phone number.
{2Patient}'s Email*
example@example.com
{3Patient}'s Phone Number*
Please enter a valid phone number.
{3Patient}'s Email*
example@example.com
{4Patient}'s Phone Number*
Please enter a valid phone number.
{4Patient}'s Email*
example@example.com
{5Patient}'s Phone Number*
Please enter a valid phone number.
{5Patient}'s Email*
example@example.com
{6Patient}'s Phone Number*
Please enter a valid phone number.
{6Patient}'s Email*
example@example.com
{7Patient}'s Phone Number*
Please enter a valid phone number.
{7Patient}'s Email*
example@example.com
{8Patient}'s Phone Number*
Please enter a valid phone number.
{8Patient}'s Email*
example@example.com
{9Patient}'s Phone Number*
Please enter a valid phone number.
{9Patient}'s Email*
example@example.com

Financial Policy
Thank you for choosing Tenth Street Pediatrics as your child's health care provider. The following is a copy of our financial policy. Patient care is not permitted without the written consent of the receipt and acknowledgement of the understanding of this policy.
Payments: Payment, in full, is due at the time of service. This includes applicable co-pays, co-insurance, and payments for services not covered or denied by the insurance company. Tenth Street Pediatrics accepts cash, personal check, debit cards, and credit cards.
Initials*
Apply initials to all
Self-Pay Accounts: If you do not have insurance or your insurance is inactive on the day of your appointment, please come prepared to pay for your visit in full upon checkout.
Initial*
Missed Appointments: Missed appointments represent a cost to us, you, and to other patients that could have been seen during the time set aside for your child. Cancellations are required 24 hours prior to any well visit appointment and two hours prior to any sick visit appointment via phone call to the practice. A “no show” fee of $50 will be applied if an appointment is missed and not cancelled within the stated time frame.
Initial*
Outstanding Balances: If you have a personal balance on your account, a monthly statement will be sent. Unless authorized in writing, payment is due upon receipt of statement or within 30 calendar days.
Initial*
Payment Plans: Tenth Street Pediatrics understands that full payment may not be possible in certain circumstances. As a courtesy, Tenth Street Pediatrics may offer the assigned account holder a payment plan. Payment plans are approved on a case-by-case basis and may be discussed with our management team. Patients with a payment plan must be in full compliance with all conditions of the agreement at time of visit. Payment plans require a credit card on file to be automatically billed according to the agreement. Failure to make scheduled payments on the payment plan, or not paying off a balance in full may result in your account being turned over to a collection agency and your family dismissed from the practice.
Initial*
Returned Checks: A $30 fee will be charged for any checks returned for insufficient funds.
Initial*
Insurance: Tenth Street Pediatrics is currently contracted with many (but NOT all) PPO plans for Anthem Blue Cross, Blue Shield, Cigna, Aetna, and United Healthcare insurance (this does not include POS, EPOS, EOS, or HMO plans). For all non-contracted PPO plans, payment in full is due at the time of each visit. We will bill your insurance company directly for you as a courtesy. Please contact your insurance company to verify we are listed as a contracted provider and what services are covered by your insurance plan before scheduling an appointment. All non-covered services will be billed to the account holder.
Initial*
Administrative Fee: Tenth Street Pediatrics charges a yearly administrative fee. This fee reimburses us for all "non- covered" services such as extended hours on weeknights, longer appointment times for check ups, completing school/sports/camp forms, all phone calls including reviewing lab results over the phone, on-call access to one of our board certified pediatricians 24/7, phone follow-up after visits when needed AND keeping our office open 365 days a year, including all weekends and holidays This fee will be due each calendar year and varies based on age and number of children from your family that are being seen by our practice.
Initial*
Forms Fee: There is a $30 fee per form for all school/sports/camp forms if the administrative fee is not paid. Turnaround for forms is usually 2-3 days. If you require the form be completed with a shorter turnaround, there will be a $25 rush fee per form, and it will be completed within 24 hours.
Initial*
Change of Insurance/Change of Account Information: Please notify the office as soon as possible of any and all account changes, including co-pay amounts, insurance updates, and change of mailing address. If the account holder does not notify the office within 15 calendar days of these changes the assigned account holder becomes responsible for any and all charges.
Initial*
Credit Card on File: As of January 1, 2022 Tenth Street Pediatrics is now requiring all patients to keep a valid credit card on file with our office. The credit card on file will be used to charge any balances or copays if an alternate method of payment is not provided.
Initial*
Review and consent of this policy is required prior to services rendered.
My initials above and signature below certifies that I have read and consent to the outlined policies and procedures.
Name of Parent/Guardian *

First Name Last Name
Printed Name of Parent/Guardian*
Signature of Parent/Guardian*

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Date*

MonthDayYear
Date
Email*
example@example.com

Open Payments Database Notice
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
Name of Parent/Guardian *

First Name Last Name
Signature*

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Date*

MonthDayYear
Date

Administrative Fee Agreement 2023
I agree to an administrative fee being charged. I understand this fee covers costs for items and services that may not be associated with medical services and are not reimbursed nor covered by my health insurance plan.

The cost of the annual administrative fee will be calculated using the age of the youngest child in the family as the “base” fee. Each additional child, regardless of age will be charged an additional $200.00 fee. To prevent the fee from becoming excessive we have put a cap of $1,000.00 per family.

For new families only: The admin fee will be prorated on a quarterly basis for the 1st year if you join the practice after April 1st.

Administrative Fee Template

Age	Fee
0-12 months	$500.00
1-4 Years	$425.00
5-11 Years	$375.00
12-17 Years	$250.00
18+ Years	$200.00

Example

Youngest child is 7 months old	= $500.00
Second child is 6 years old	= $200.00
Third child is 10 years old	= $200.00
Fourth child is 13 years old	= $100.00
Total:	= $1000.00

Patient name(s) and age as of January 1, 2023*
Please enter each child on a new line
Name of Parent/Guardian*

First Name (Parent)Last Name (Parent)
Signature*

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Date*

MonthDayYear
Date

Patient Contact Information

Financial Policy

Open Payments Database Notice

Administrative Fee Agreement 2023

Patient Race & Ethnicity