Welcome to Alzein Pediatrics!

Please remember that copays are due at time of service.  Thank you!

Please identify your preferred pharmacy. When you need prescription medication, we'll call the prescription into this pharmacy.

 

I authorize my treatment by a Provider employed by Alzein Pediatrics. I authorize the release of any information concerning my healthcare, advice, and treatment provided for the purpose of evaluation and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the Provider, realizing I am responsible to pay non-covered services. I am also aware of the payment and fee policies of Alzein Pediatrics.

The doctors at Alzein Pediatrics contract with most insurance plans. However, it is my responsibility to understand the benefits provided in my insurance plan. I am responsible for insurance copayments at the time of my visit, and I am also responsible for any outstanding balance once my insurance claim has been processed. I authorize payment of medical benefits directly from my insurance carrier to the treating physician for services provided.

Please specify family members using the following initials of whom had the following illnesses.

M- Mother F- Father B- Brother S- Sister PG-Paternal Grandfather PGM -Paternal Grandmother MG - Maternal Grandfather MGM - Maternal Grandmother

I understand and acknowledge that as of my 18th birthday, my parents and/or guardians will no longer be permitted access to my medical records, information, providers, or appointment status without my specific written permission. Alzein Pediatrics will not speak with my parents, permit my parents to schedule appointments, or release medical information to my parents without my written consent in accordance with this document. 

I understand that:

1. The purpose is provided above so that I can make a decision as to whether to allow the release of information.

2. The disclosing office will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI, except for minimum fees for copying and postage.

3. I do not have to sign this authorization in order to receive treatment.

4. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule or other law protecting its confidentiality.

5. I have the right to revoke this authorization in writing, except where the office has acted in reliance upon it. My written revocation must be submitted to: Alzein Pediatrics, 2850 W. 95th Street, Suite 400,Evergreen Park IL 60805 OR to the Privacy Officer of the facility that is releasing information.

6. This form may be deemed INVALID if all sections are not completed.

In an effort to provide a safe and healthy environment for staff and patients, Alzein Pediatrics expects patients, parents and accompanying family and friends to refrain from unacceptable behaviors that are disruptive or pose a threat to the rights or safety of other patients and staff. The following behaviors are prohibited and may result in your immediate dismissal from the practice:
• Physical assault or inflicting bodily harm.
• Rude behaviors in person or through written, verbal or electronic communication, including but not limited to the following: Profanity, harassment, offensive or intimidating statements or gestures and threats of violence.
• Racial or cultural slurs or other derogatory remarks associated with race, language, or sexual orientation.
• Requests that would constitute illegal or unethical behavior on the part of Alzein Pediatrics.

PLEASE BE COURTEOUS WITH THE USE OF CELL PHONES/VIDEO AND OTHER ELECTRONIC DEVICES. WE RESPECTFULLY ASK THAT YOU PUT YOUR DEVICES AWAY WHILE INTERACTING WITH THESTAFF, AND PROVIDERS.

WE ARE MAKING EVERY EFFORT TO REDUCE WAIT TIMES AND MAKE ALL OF OUR PATIENTS' VISITS TO ALZEIN PEDIATRICS AS STRESS FREE AND ENJOYABLE AS POSSIBLE. TO ASSIST IN THAT GOAL, WE HAVE THE FOLLOWING EXPECTATIONS:

Please arrive on time for your appointment. It would be ideal for you to arrive 10-15 minutes early for your appointment. Arrive 10-15 minutes early is especially important when your appointment is our first in the AM.

Arriving more than 15 minutes late may result in having to reschedule. When you arrive late, you are taking up someone else's designated time. This has a domino effect on every subsequent visit and is a contributing factor to long wait times.

❖ Please provide 24 hours notice of cancellation whenever possible. We understand that last minute situations arise. Any notification, even late notice is appreciated.

❖ MISSING an appointment without prior notification will result in a $50 no show fee, That will need to be paid before your childs next appointment.

Please ensure a parent or responsible adult attends all appointments with patients that are 17 years and'below This is necessary to obtain legal consent for all procedures and treatments, including vaccinations.

❖ Payment of copays and full balances is expected at the time services are rendered, regardless of who brings the child to their appointment. Failure to do so may result in having to reschedule your appointment.

❖ Please do not leave your children unattended in the office. If you need to use the rest room, please inform one of our staff members to help you with your children.

❖ To ensure your children's safety, we ask that you not allow your children to climb on the furniture in the waiting area.

I agree to the Alzein Pediatrics "Code of Conduct for Patients, Parents and Visitors"

We are committed to providing you with the best possible care. If you have medical insurance, we wish to help you receive your maximum allowable benefits. To achieve this, we need your understanding of and assistance with our financial and payment policy.

Insurance: For your convenience, we will submit your claim and assist you in any way we reasonably can to get your claim paid. Insurance plans vary considerably and we cannot predict or guarantee what part of our services will or will not be covered. It is your responsibility to know your individual policy and to verify all benefits and coverage information prior to having services rendered. Your insurance policy is a contract between you and your insurance company.

Proof of Insurance: Proof of insurance must be shown at check-in at every visit. Without proof of insurance, you will be charged for the visit in full.

Change of Insurance/Change of Address: Please notify the office as soon as possible of all insurance and address changes. If the guarantor does not notify the office within 15 days of any changes the guarantor is responsible for all charges not paid because of change in insurance coverage.

Self-pay: We do everything we can to mitigate the expense of anyone who is uninsured. Alzein Pediatrics provides a discount for self-pay patients. Payment is expected in full at the time of service for all charges.

Co-Payments: We’re contractually obliged to collect, and you’re responsible to pay, your co-payment at the time of your visit. Please have your co-payment ready at check-in.

Deductibles & Coinsurance: Depending on your insurance policy, a deductible or coinsurance may be required at the time of service. Once the co-insurance amount has been established, the amount due at each visit will be the coinsurance percentage of the charges incurred, plus any deductible not yet met for the year.

Outstanding Balances: Any amount not covered by the insured/patient’s insurance is due within 30 days of the time of service. Balances on account must be paid prior to receiving additional services. Accounts will be turned over to a collection agency if past due 60 days or more. The patient family will be responsible for all collection costs involved with the collection of this account including court cost, reasonable attorney fees and all other expenses incurred with collection if there is a default on any unpaid balance. Should you have extraordinary financial pressure, we will assist you with a payment plan, agreed to in writing with our billing department prior to services being rendered.

Coordination of Benefits: Responsible parties must respond to a request for information from the insurance within 10 business days. A failure to respond to a request for COB information from the insurance will result in all charges becoming patient responsibility.

Cancellations: Our office charges a $50.00 no show fee for missed appointments. If you need to cancel your appointment, please contact us at least 48 hours in advance. This charge is not covered by your insurance and is the responsibility of the parent/legal guardian.

Transfer of Records: Should you wish to transfer care to another physician, you will need to complete the authorization to release records form, which can be obtained from any of our clinic locations. This form needs to be completed in its entirety for us to process the request. All balances must be paid in full before records are transferred. A copy fee of $75 must be paid before the records are released. 

The doctors at Alzein Pediatrics contract with most insurance plans. However, it is my responsibility to understand the benefits provided in my insurance plan. I am responsible for insurance copayments at the time of my visit, and I am also responsible for any outstanding balance once my insurance claim has been processed. I authorize payment of medical benefits directly from my insurance carrier to the treating physician for services provided.