Know your policy! Most plans
have deductibles, coinsurances, and/or co-payments that are solely your
responsibility at the time of your visit. We accept cash, check, Visa or
Mastercards, you also have the option of leaving your credit card on file to be
charged as balances accrue. If a personal check is bounced you will be charged
a fee of $35.00 plus the cost of the original balance. Co-payments not
collected at the time of visit will be charged a $10.00 fee plus the amount of
On arrival, please sign in at our front desk and
present your most current insurance
card. If the insurance company
that you present is incorrect, you will be responsible for payment of the full
cost of the visit and will be required to submit the charges to the correct
Certain insurances require you to select a Primary Care
Physician or a PCP. Please call your insurance prior to the visit and select
one of our Heights Pediatrics physicians, if they have not been notified you
may be financially responsible for this visit and/or your appointment will need
to be rescheduled.
We do not submit to secondary insurance plans.
If you have a secondary insurance, you must pay the balance and we can provide
you with a receipt to submit for reimbursement. You are responsible for any
balances on your account.
It is your responsibility to understand your benefits
and to know if you require referrals for specialist visits. Referrals and prior
authorizations for services and medications require at least 3 business days to
complete. No retroactive referrals can be provided.
If our physicians are not on your insurances panel or
you do not have insurance, then payment in full for services provided are
required at the time of visit. For appointments that have already been
scheduled, any and all prior balances must be paid prior to being seen.
Patient balances are billed immediately once your
insurance plan’s explanation of benefits (EOB) has been received by our office.
Your payment is due within 10 business days of your receipt of your bill.
If you are unable to keep your scheduled appointment,
we require you to contact our office within 24 hours before your appointment to
reschedule or cancel. This will allow us to have another patient who needs that
appointment to come in. If you do not contact us within 24 hours, we will
charge a fee of $50.00 for each child that was scheduled to be seen.
Any balance over 60 days will be forwarded to a
We charge $20.00 per child for each copy or transfer of
If your child has a school, camp, or sports form to be
completed there is a $20.00 charge for each form to be filled out. If you require
a standard print out in our system we will charge a fee of $5.00 for each form
needed. Payment is due when the forms are dropped off. The turn around time for
forms to be completed is 2-3 business days.
Before scheduling your child’s annual physical appointment,
check with your insurance company whether the visit will be covered as a
healthy visit. Not all plans cover vision and hearing screens as well as the
physical exam. It is your responsibility to know your insurance benefits. If
services are not covered, you will be responsible for payment at the time of
Not all services we provide are covered by every plan;
those services that the insurance determines to not be covered will be your
Please call our office if you have a question about your
bill. Most problems can be resolved quickly and your call will prevent
misunderstandings. If you have trouble paying a bill, please discuss the
situation with us and arrangements can be made. Financial considerations should
never prevent children from receiving the care they need at the time that it is
I have read and
understand this office policy and agree to comply and accept the responsibility
for any payment due.
Heights Pediatrics –
Office Financial Policy
I have received a copy
of and understand this office policy and agree to comply and accept the
responsibility for any payment due.
party member’s name
party’s signature Date