Thank you for choosing us as your child’s health care provider. We are committed to providing your child comprehensive Pediatric care. Please understand that payment of your child’s bill is considered part of their treatment. The following is a statement of our financial policy which we require you to read and sign prior to any treatment.
ALL PARENTS MUST COMPLETE ALL PAPERWORK BEFORE THEIR CHILD IS SEEN.
All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.
If a check is returned to us for any reason, your child’s account will be charged the amount of the check plus a $ 25.00 returned check fee. Parents will be responsible for any fees incurred from collection agencies and/or legal services hired by POWERS PEDIATRICS to secure payment for services.
USUAL & CUSTOMARY RATES
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual or customary rates.
INSURANCE
WE CANNOT BILL YOUR INSURANCE COMPANY UNLESS YOU GIVE US A COPY OF YOUR CHILD’S INSURANCE CARD. Without a copy of the card, you will be responsible for 100% of the charges on that date of service. We will file to your insurance company; however, if you must pay a percentage of the bill, it must be paid at the time of service. All co-pays are due at the time of service.
The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. Please be aware that some, and perhaps all of the services provided may be non-covered services and not considered reasonable according to your insurance policy.
According to Florida State statutes, an HMO has 45 days to process and pay a correct claim. If your insurance has not paid your child’s claim in full within 6 months, you will be responsible for the bill within 10 days of receipt of your statement.
We will mail 2 statements to you before the account is turned over to a collection agency. If you are unable to pay the balance in full, we can arrange a payment plan for you which you will sign. A copy of the payment plan will be given to you and copy will be kept in your child’s chart. If you default on your payment plan, the account will be forwarded to a collection agency.
In the event that your insurance changes, it is your responsibility to notify us as we may be non participating providers. Failure to do so will result in you being responsible for all charges incurred. It is not the responsibility of POWERS PEDIATRICS to ensure we are providers. Our main concern is the health of our patients.
Regarding HMO, Managed Care and Medicaid plan, you are responsible for making sure that our practice and/or doctors are listed as your child’s Primary Care Physicians. Failure to do so will result in you being responsible for all charges incurred.
Assignment of Benefits
I hereby assign all medical, dental and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrieres), including Medicare, private insurance and any other health/medical and dental plan, to issue payment check(s) directly to POWERS PEDIATRICS for medical and dental services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
Authorization to Release Information
I hereby authorize POWERS PEDIATRICS to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing.
I have requested medical services from POWERS PEDIATRICS on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.
I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
Your Signature Below Confirm that you fully understand POWERS PEDIATRICS financial policy.
