We’re a big fan of clear communication, making sure you and your children know what to expect when you visit us and giving you a roadmap for your family’s health. So you won’t have any surprises, we’ve prepared a statement of Practice Policies that we’ll ask you to sign. Most of the information concerns our approach to permissions, financial charges, and appointment procedures.
Please read these policies. They involve our work together to protect your child’s health and are very important. We’ve done everything we can to keep them short!
- Your current address, telephone number and insurance information will be requested at each visit. If current insurance cannot be verified, or if a Northside Pediatrics Physician is not listed as the primary provider for your child, we will require payment in full for services rendered.
- If your managed care plan requires a PCP (primary care provider) in order to see a subspecialist, a referral request must be completed in advance of your appointment. Our office requires 72-hours notice to process the referral request.
- All co-payments are due at the time of service, as per our contract with your insurance carrier. Failure to pay a co-payment will result in a $25 billing fee.
- Well-check appointments require a 24-hour cancellation notice. Sick appointments require a 4-hour cancellation notice. Cancellation notices given within less than the requested time will result in a $50 cancellation fee.
- Written and verbal information will be provided at each visit where vaccines are administered, and verbal consent will be requested prior to administering any vaccine.
- If verbal consent is provided and later withdrawn after vaccine doses have been prepared for your child, the full cost of vaccines will be billed.
- Some laboratory charges may be provided by Quest Diagnostics or LabCorp, which are contracted outside labs.
- All medical-records requests must be in writing and received in our office 7-10 days prior to the date needed. Records can be mailed or faxed, and all medical-records requests will have a fee based on the number of pages. This includes camp forms, immunizations, etc.
- A Health/Immunization form will be provided at the time of your child’s well check-up at no charge. Replacement forms will be provided at a charge of $10. Other forms (camp, school, sports, etc) completed at the time of a check-up appointment are also provided at no charge. Forms completed for your child at any other time will incur a charge of $10 for the first three, and $10 for each form thereafter.
- If you have an insurance we contract with, we will gladly file your visit to your carrier. However, you are ultimately responsible for any unpaid balance on your account.
- You understand and agree that in the event of default in paying a patient-due balance, you will be responsible for reasonable collection charges and/or court costs and attorney fees.