March 28, 2018
Pediatric Medical Care Patient Financial Agreement
We are committed to providing you with quality and affordable health care. We ask all patients to review and sign this policy, asking questions as necessary. A copy will be provided to each patient upon request.
1. Insurance: We accept assignment and participate in most insurance plans. If your insurance is not a plan we participate in, payment in full is expected at each visit. Knowing your insurance benefits is your responsibility. Please contact your insurer with any questions you may have regarding your coverage to receive the maximum benefit.
​
2. Patient payment: All copayments and deductibles are to be paid at the time of service. This arrangement is part of your contract with your insurance company.
​
3. Registration: All patients must complete our patient information form, which will be entered into our computer to maintain accurate information for proper billing. If you fail to provide us with the correct insurance information, or your insurance changes and you fail to notify us in a timely manner, you may be responsible for the balance of a claim. Most insurance companies have time filing restrictions; if a claim is not received within 30 days of the date of service, it can be rendered ineligible for payment and you will be responsible for the balance that remains.
​
4. Claims: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may not accept information from our office and may need information from you. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether your insurance company pays or not. Your insurance benefit is a contract between you and the insurance company; we are not party to that contract.
​
5. Uninsured patients: We offer a 25-percent discount to our patients who do not have insurance. Please be advised that the discount is only good when the charges are paid at the time of service. If the charges are not paid at the time of service, the discount will be removed and payment of the full charge will be expected before the next visit. If a balance remains, you will receive a monthly statement that is due upon receipt. Any account balance over 90 days will be subject to review for collection action.
​
6. There is a $25 returned check fee in the event a patient’s personal check is returned to us for any reason, and we will no longer be able to accept checks from you.
​
7. Credit and collection: If your account is more than 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance has remained unpaid, it may be sent to a collection agency. You will at that time be notified by regular and certified mail that you will have 30 days to find alternative medical care. During that 30-day period our physicians will be able to treat you only on an emergency basis directly to you.
Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. The Undersigned (who is the*responsible party for the patient) has read and agrees to the above financial policies of Pediatric Medical Care, Inc.
​
Signed________________________________________________________Date:____________
​
*Responsible party--the parent or guardian who is responsible for paying the patient’s medical bills