The patient’s legal representative consents to the treatment and services which may be performed during this and any future visits, and which may include but are not limited to laboratory procedures, examinations, treatments or procedures, or other services rendered under the general or specific instructions of the physicians or health care providers.
“Walk-in” and “sibling add-on” appointments are not accepted. We want to take care of your child’s illness; however, it is unfair to ask our patients who have a scheduled appointment to wait while someone without a pre-scheduled appointment is seen. If you feel that your child cannot wait to be seen, ask to speak to the triage nurse for evaluation and they will make a recommendation.
If you are unable to arrive for your appointment on time, please call to inform the staff. They will review the schedule to determine if the appointment will need to be rescheduled or work you in behind other scheduled appointments.
Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these.
Missed Appointment Fee:
Patients who do not show up on time for an appointment, or cancel with less than 24 hours’ notice will be charged a $25 fee. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another doctor.
There is a fee (currently $25) for any checks returned by the bank. NSF checks must be redeemed with certified funds (money order, certified check, or cash.) You will no longer be able to make payments on your account with a check; instead future payments will need to be cash or credit only.
If you have a balance on your account, we will send you a monthly statement. Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the end of the month.
Past Due Accounts:
If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, there will be a $25 surcharge fee imposed on your account and you agree to pay all of the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all of the lawyer’s fees which we incur plus all our court costs. In case of suit, you agree the venue shall be in Phoenix, Arizona.
Charges to Account:
We shall have the right to cancel your privileges to make charges against your account at any time. Future visits would then need to be paid in full at the time of service.
Waiver of Confidentiality:
You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent. We do NOT recognize or enforce the terms of divorce decrees nor accept third party assignments of any kind.
We require that a legal guardian accompany a minor patient unless prior written authorization is given to this office. The adult accompanying the minor is required to pay in accordance with our policies.
We require that you notify the scheduler when you make an appointment of any changes to insurance, address and/or telephone number. By doing so, this will eliminate unnecessary delays in your child’s care.
The provider is required to code the visit based on all care provided and if an abnormality is encountered or a preexisting problem is addressed in the process of performing a preventive exam, and/if the abnormality/problem is significant enough to require additional work (either during the visit or after), then separate billing for a problem visit may occur. With this in mind, while the appointment may have been scheduled for just a preventative exam or just for a problem(s), if both types of services are provided during the exam then both types of services may be billed. We cannot change the coding after it has been submitted to your insurance company in order for them to pay non-covered services.
If we are contracted with your insurance company, we must follow our contract and their requirements. If you have a co-pay or deductible, you must pay at the time of service. It is the insurance company that makes the final determination of your eligibility.
Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.
Transferring of Records:
You will need to request in writing, and pay a reasonable copying fee of $10 if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.