1. In accordance with our contract with your insurance company, we are obligated to take the co-payment defined by your insurance plan. Co-payment is due at the time of service. This includes any siblings that are added to the schedule at the time of another visit.
2. A $20 fee will be charged to your account for NSF checks that are returned by your bank. After two NSF checks have been returned on your account, we will request payment by cash or credit only.
3. If a personal balance is due after insurance has responded for a date of service, a statement will be sent to the responsible party. Payment in full is expected upon receipt of the first statement. Please do not disregard any statements you receive from our office. Please call our billing department if you have any questions or feel there are any errors.
4. It is understood that if your account is turned over to a collection agency, you will be responsible for any collection costs that are incurred. Once an account is sent to collections, a general discharge policy will take place.
5. Remember that payment arrangements can be made at any point during this process prior to the account being sent to a collection agency. However, once this step has been taken, we cannot reverse the process of collections nor the discharge from the practice in general.
6. Any visits scheduled after our regular office hours will be billed as such to your insurance company.
7. Comprehensive Administrative Plan "CAP," a yearly fee $50/patient with a family maximum of $150.00 billed yearly on October 1st. CAP allows us to provide all services not billable through your insurance company under a single yearly fee.
INSURANCE CARDS MUST BE PRESENTED AT EACH VISIT
All professional services rendered are billable to insurance. All efforts to bill claims to your insurance will be made. However, the guarantor is responsible for charges if correct insurance is not given within the timely filing limits as set forth by the individual's insurance company. All co-pays are due at time of service. Per the agreement with your insurance, you will be billed for coinsurance or deductible balances. Payment is due upon receipt of our statement unless alternate payment arrangements are made with our billing manager.
Insurance Authorization and Assignment
I request that payment authorized Medicare/Other Insurance Company benefits be made either to me or on my behalf to Connecticut Pediatric Partnership, LLC. For any services furished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or related Medicare claim/Other Insurance Company claim. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown in Medicare/Other Insurance Company as the full charge and the patient is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and the deductible are based upon the charged determination of the Medicare/Other Insurance Company.