Heights Pediatrics - Office Financial Policy


Thank you for choosing Heights Pediatrics as your child’s pediatricians and as one of our patients we would like to inform you of our current office financial policies. Once you have carefully read the following please sign this document and return to our office staff. If you have any questions, do not hesitate to ask one of our staff members.

  1. 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 the co-pay.

  2. 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 plan.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. Any balance over 60 days will be forwarded to a collection agency.

  10. We charge $20.00 per child for each copy or transfer of medical records.

  11. 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.

  12. 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 the visit.

  13. Not all services we provide are covered by every plan; those services that the insurance determines to not be covered will be your responsibility.


    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 needed.


    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.


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                      Patient Name(s)                                           Responsible party member’s name




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          Responsible party’s signature                                                        Date