Financial and Billing Policies
Credit Card on File:
It is our practice policy to require all families to keep a credit card on file with us. This allows us to promptly collect the amount your insurance carrier says is your responsibility. Co-payments will be charged to your card on the date of service. Deductibles, coinsurance, and non-covered charges up to $200 and less will be charged to your credit card upon receipt of the Explanation of Benefits (EOB) from your insurance company. Your credit card information will be kept confidential and secure as required by the PCI Securities Standards Council.
Please click the link or SCAN to complete the Credit Card on File Authorization Form
https://form.jotform.com/240106248336147
*This will go into effect on 3/18/2024
Co-Pays:
In accordance with our contract with your insurance company, we are obligated to take the co-payment defined by your insurance plan. Co-payment is due at the time of the visit by the person who brings the child to the office. For your convenience, we accept cash, checks, and all major credit cards.
*Effective 1/10/2024
Patient Balances:
As a courtesy to our patients, Doctors’ Pediatric will bill your insurance company. Please remember that your insurance is a contract between you and the insurance company, not the doctor. You are responsible for any charges or portion thereof for which payment is denied by insurance for any reason, except where prohibited by law or prior contractual agreement. A statement will be sent to the responsible party and is due upon receipt. Balances and/or unpaid claims after 60 days will be required to be paid in full or financial arrangements will have to be made before any future appointments can be scheduled. Please call our billing department immediately if you have questions about a statement you received or feel that there are any errors.
Unless other arrangements are made with our billing department, we may refer unpaid bills to a collection agency after 90 days. If your account is turned over to a collection agency, you will be responsible for any collection costs that are incurred. Once an account is sent to collections, a general discharge policy will take place. Remember that payment arrangements can be made at any point during this process prior to the account being sent to a collection agency. However, once this step has been taken, we cannot reverse the process of collections nor the discharge from the practice in general.
*Effective 1/10/2024
Services Rendered:
Not all services are a covered benefit in all contracts. In most cases, any non-covered service is your responsibility. Please take the time to understand the insurance plan you have and refer to our website for the schedule of well visits to see the services provided at each visit. If you do not understand your specific plan coverage, please call your insurance plan or your HR department at work. The number for your plan is listed on your insurance card.
If a child is seen for a well check-up and another condition is treated during the same appointment, we will bill for each of the services performed in accordance with CMS National Correct Coding Initiative (NCCI) standards. This may result in a co-pay being assessed by your insurance company, or charges being applied to your annual deductible.
*Effective 1/10/2024
Insurance:
Please be prepared to provide your insurance card to the front desk at every visit. All HMO plans require that you select your primary care provider. If the assigned Doctor’s name on your card is not one of our providers, your visit will not be covered. Please call the number on the back of your card to formally select our practice. If insurance coverage is not in place at the time of a visit, or if our providers do not participate with your plan, you will be responsible for paying in full with a cash discount.
It is your responsibility to inform us of any change in your insurance coverage. It is important that we have the correct billing information. If a claim is not received by your insurance company in a timely manner, they can deny the claim, making you responsible for payment.
*Effective 1/10/2024
Cancellations and Missed Appointments:
If it is necessary to cancel your appointment, please call the office and speak to a staff member AT LEAST 24 hours prior to the appointment. If you do not call, we cannot give that appointment to another child who may need it! Failure to cancel the appointment will result in a no-show charge of $75. The no-show charge for a missed sick appointment is $50. Emergencies will be considered on a case-by-case basis for a waiver of any fees.
As a courtesy, we provide text and email reminders of your scheduled appointments, however, you are still responsible for the cancellation even if you did not receive an email and/or text.
*Effective 1/10/2024
NSF Checks:
A $20.00 fee will be charged to your account for NSF checks that are returned by your bank. After two NSF checks have been returned on your account, we will request payment by cash or credit card only.
*Effective 1/10/2024
Health Forms:
We will provide your child with one school health form free of charge at their annual check-up. If you require additional/replacement forms, there is an administrative fee of $10 per form. There is a $10 administrative fee for each camp form processed. The fee is payable at the time of pick up.
*Effective 01/10/2024
Miscellaneous Policies:
18 and up:
Once our patients turn 18, by law, we are required to have a signed permission to speak form on file. This form must be completed and signed by the patient themselves. Parents, we understand that it may be frustrating when you call the office and are told that we need the signed form before a provider or nurse can speak with them, but this is the law and we must follow it.
Click HERE to print out the 18 & up HIPAA Release and Consent Form
*updated 5/18/2023
Record Release Policy:
The charge for copying records is $15 per child, payable up-front at the time of the request. We will make every effort to make the copies available as soon as possible but please know that, by law, we have up to 30 days.
Click HERE to print out the Record Release Form. Once you have completed the Record Release form, you can drop it off, fax it, or mail it. We understand that under certain situations you may need to email the form. Please call the office to obtain the email address to use.
*updated 7/19/2024
Do you need a prescription refill?
Effective immediately, we have updated the prescription refill policy.
- Please plan ahead, especially when it comes to vacations and holidays! ALL prescription refill requests will require at least 3 business days’ notice.
- Prescriptions for ADD/ADHD medication or any other controlled substance will only be refilled Monday through Friday.
Please note: States are increasingly restricting our ability to send out-of-state prescriptions, especially controlled substances (i.e. ADD/ADHD medication). We echo your frustration with how this changes our ability to prescribe medication when your child is out of state. In order to prescribe the appropriate medication to our patients, we will need to send the prescription to a local pharmacy. Parents will then need to bring or mail the medication to their children. As many of you may know, doctors are not allowed to send more than 30 days of a controlled medication to local pharmacies. Express scripts will allow a 90-day prescription. This may be an option to make this situation more manageable.
*updated October 2, 2024