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Office Policies

Click HERE to download this policy in PDF format.

Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal. Please read this carefully and if you have any questions, please do not hesitate to ask a member of our staff.

  1. On arrival, please sign in at the front desk and present your current insurance card at every visit. You will be asked to verify and sign that the information printed on your child's superbill is correct. This is your verification of the correct insurance and consent to bill them on your child's behalf. IF THE INSURANCE COMPANY THAT YOU DESIGNATE IS INCORRECT, YOU WILL BE RESPONSIBLE FOR PAYMENT OF THE VISIT AND TO SUBMIT THE CHARGES TO THE CORRECT PLAN.
  2. If we are your primary care physician, make sure our name or phone number appears on your card. If your insurance company has not been informed that we are your primary care physicians as of this date, you may be financially responsible for the visit.
  3. According to your insurance plan, you are responsible for any and all co-payments, deductibles, and coinsurances.
  4. We do not submit to secondary insurance plans. If you have a secondary insurance, we will provide you with a receipt to submit for reimbursement. Your secondary insurance will send the reimbursement check directly to you. YOU ARE RESPONSIBLE FOR ANY BALANCE ON YOUR ACCOUNT.
  5. It is your responsibility to understand your benefit plan. It is your responsibility to know if a written referral or authorization is required to see specialists, if preauthorization is required prior to the visit.
  6. If our physicians do not participate in your insurance plan, payment in full is expected from you at the time of your office visit. For scheduled appointments, prior balances must be paid prior to the visit.
  7. If you have no insurance, payment for an office visit is to be paid at the time of the visit.
  8. Co-payments are due at time of service. A $15.00 processing fee will be charged in addition to your co-payment if the co-payment is not paid within one week of your visit.
  9. Patient balances are billed immediately on receipt of your insurance plan's explanation of benefits. Your remittance is due within 10 business days of your receipt of your bill.
  10. If previous arrangements have not been made with our finance office, any account balances outstanding greater than 28 days will be charged a 1.5% re-bill fee. Any balances over 90 days will be forwarded to a collection agency.
  11. If you participate with a high-deductible health plan, we require a copy of the health savings account debit/credit card or a personal credit card to remain on file. There are addenda to this financial policy, which are signed separately.
  12. We require 24-hour notice for canceling any appointments. There is a $22.00 charge for appointments if they are not canceled or if 24-hours notice is not given.
  13. A $25.00 fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.
  14. We charge $1.00 per page for the first 25 pages and .25¢ for each additional page to copy or transfer medical records.
  15. If your child has school, camp or sport forms to be completed, there is a $5.00 charge per form. Payment is due when the forms are picked up. We have a 3 to 5 day turnaround time for forms. If a form is needed sooner than 3 days, there is additional $5.00 rush fee. One (1) school or camp, or sport form will be provided at no charge at the time of the Well Child Visit, if the form is not requested during this visit, the above charges apply.
  16. Advance notice is needed for all non-emergent referrals, typically 3 to 5 business days. It is your responsibility to know if a selected specialist participates in your plan. Remember your primary care physician must approve referrals before being issued.
  17. Before making an annual physical appointment, check with your insurance company whether the visit will be covered as a healthy visit. Not all plans cover annual healthy physicals or hearing and vision screenings. It is your responsibility to know your insurance plan benefits. If it is not covered, you will be responsible for payment at the time of visit.
  18. Vaccines for Parents – payment is expected at the time of service. Due to the nature of this service, we can not bill your insurance. A superbill will be provided to you so that you can submit the bill yourself for reimbursement.
  19. Our office is available for sick and emergency visits on nights and on weekends. There is an additional charge for this service.
  20. Not all services provided by our office are covered by every plan. Any service determined to not be covered by your plan will be your responsibility.

I have read and understand this office financial policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously.