Office Policies 2019

Please list your children.*

First Name	Middle Initial	Last Name

OFFICE POLICIES

Some Charges May NOT be Covered by Insurance*

I agree.

Some procedures and services may not be covered by my insurance policy. 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

Missed Appointments*

I agree.

The charge is $75 if I fail to cancel an appointment 2 hours before the scheduled time.

Arriving Late to an Appointment*

I agree.

If I arrive more than 10 minutes late, my appointment WILL be rescheduled. Medical emergencies are the ONLY exception to this rule.

After-hours Nurse Line*

I agree.

I understand to use the after hours nurse telephone service is $17 per call.

Transaction Recordings*

I agree.

I understand that Pediatric People PLLC may record inbound and outbound telephone calls, including verbal conversations within all Pediatric People facilities.

Form Completion Without a Visit*

I agree.

I understand that 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

CREDIT CARD ON FILE

Cardholder Name*

First Last

Last 4 Digits of Credit Card Number*

Credit Card Expiration Date*

Required Credit Card On File*

I agree.

I must keep a valid credit card on file. I authorize Pediatric People PLLC to charge my credit card for any amount not covered by my insurance company.

CCOF Authorization Form
I, the Cardholder, do hereby authorize Pediatric People PLLC to charge my credit card all charges not covered by my insurance company.

This agreement shall remain in effect until the specific credit card expires, or until revoked by written notification from me, or at the discretion of Pediatric People PLLC.

Signature of Parent or Legal Guardian*

2019 OFFICE POLICIES

OFFICE POLICIES

CREDIT CARD ON FILE