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Office Policies Agreement
Michael
2024-09-11T15:55:08-05:00
OFFICE POLICIES AGREEMENT
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PATIENT 1
Patient 1 Name
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Patient 1 Date of Birth
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Patient 1 Gender
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PATIENT 2
Patient 2 Name
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Patient 2 Date of Birth
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Patient 2 Gender
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Female
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PATIENT 3
Patient 3 Name
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First
Last
Patient 3 Date of Birth
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Patient 3 Gender
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Female
Male
PATIENT 4
Patient 4 Name
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First
Last
Patient 4 Date of Birth
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YYYY
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Patient 4 Gender
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Female
Male
PATIENT 5
Patient 5 Name
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First
Last
Patient 5 Date of Birth
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YYYY
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Patient 5 Gender
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Female
Male
PATIENT 6
Patient 6 Name
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First
Last
Patient 6 Date of Birth
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MM
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YYYY
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Patient 6 Gender
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Female
Male
Charges for Medical Services
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I understand some services may not be covered by my insurance or may be applied to my deductible.
I agree to pay all charges, in full, once they have been processed by my insurance company, if any balance remains due. Below are the most common procedures and tests that may be applied toward your insurance deductible. These costs are approximate and will vary based on your insurance company. These charges are in addition to the office visit charge.
- Earwax Removal $65 - $75
- Lesion/Wart Destruction $125 - $175
- Sutures, Staples or Skin Glue $125 - $225
- Abscess Care $150 - $180
- X-rays & Radiologist $25 - $39
- Splinting $50 - $95
- Breathing Capacity Test $19
- Flu Test A $15
- Flu Test B $15
- Strep Test $15
- RSV Test $9
- Mono Test $7
- Medication Refill $35
Financial Policy
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I understand that insurance co-payments, deductible, self-payment or outstanding balances are due
BEFORE
my child’s visit.
We may refuse service if you have an unpaid balance.
Assignment of Benefits
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I hereby assign to Pediatric People PLLC all insurance benefits, if any, otherwise payable to me for services rendered to myself and/or my dependent(s), and I hereby authorize and direct my insurance carrier to issue payment of such benefits directly to Pediatric People, PLLC. I authorize the use of my signature, and a copy thereof, on the insurance submissions.
Missed Appointments
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I understand that I will be charged
$115
if I miss my appointment. You MUST give us
at least 2 hours notice
. You may call, email or send us a text message if you need to cancel your appointment.
Arriving Late
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I understand that if I arrive late, my appointment
WILL
be rescheduled and I will be charged
$115
.
Late Cancellations
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I understand that I MUST cancel my appointment at least 2 hours BEFORE my scheduled appointment time to avoid a $115 fee.
Secure Messaging
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I understand that this service is NOT for medical situations requiring an immediate response. I can expect up to a 48-hour response time.
After-hours Nurse Line
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I understand to use the after hours nurse telephone service is
$35
per call.
Transaction Recordings
*
I understand that Pediatric People PLLC records
ALL
inbound and outbound telephone calls, including verbal conversations within
ALL
Pediatric People facilities.
Credit Card On File
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I understand that I must keep a VALID credit card on file for any amount that is not covered by your insurance.
Form Completion Without a Visit
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I understand that I may be charged a fee to have a provider complete a form.
My physician will complete forms and prescription refills during my visit at no charge. All forms requiring medical review and a physician's signature without a visit, will incur the following charges:
- FMLA, Disability or Complex Forms - $29
- Asthma Action Plans - $19
- Allergy Plans - $19
- Sports Physical Forms - $19
- Day Care/School Attendance Forms - $9
Name of Parent or Legal Guardian
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First
Last
Signature of Parent or Legal Guardian
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Date of Signature
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IP Address
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