By signing this agreement, you understand that you are responsible for paying for the cost of services at the time of your visit.
You must pay your copayment and account/family balance at the time of your visit. If you are unable to pay your account balance at the time of a preventative visit, we may reschedule you until you are able to make the copayment or account balance payment. We will not reschedule sick visits, but you are still responsible for paying for services. Please note the parent/guardian who attends the visit is required to pay the copayment and/or balance at the time of service or arrange pre-payment to be made by the responsible party before the visit.
If you have deductible and/or coinsurance associated with your insurance plan, then you must place a payment card on file with us. The card can be a credit/debit card, a Health Savings Account ("HSA") card, or a Flexible Spending Account ("FSA") card. Once we have made the claim to your insurance company and the extent of your benefit is determined, we will charge your card on file for the difference.
At this time Frederick County Pediatrics accepts payment in the form of cash, debit/credit cards (include HAS or FSA) and personal checks. Any check returned unpaid will be assessed a $35 fee, and we may refuse to accept checks as payment after a returned check.
We understand that sometimes finances are difficult for families. If you are unable to pay your full balance, then Frederick County Pediatrics will assist you to structure a payment plan. Payment plans will spread your balance owed over the course of three months. If you need more time in your payment plan, then you must contact the Practice Administrator with a proposal. Frederick County Pediatrics has no obligation to agree to any payment plan.
If you do not have a payment plan and you have not paid your balance due for more than 90 days, Frederick County Pediatrics will place you into "collection status." Accounts that are in collection status may be referred to a collections agency to collect on the balance owed. If a family is in collection status, then Frederick County Pediatrics may choose not to see your child(ren) until the balance is paid in full. Frederick County Pediatrics may dismiss you from the practice if you are in collection status.
I certify that I have read and understood the Financial Policy.