Office and Financial Responsibility Policy
Arti Pediatrics, Inc.
Welcome to Arti Pediatrics. We strive to provide our patients with the highest quality medical care. In an effort to foster a collaborative relationship, we ask that you review our updated financial policy so that you understand your responsibilities in this relationship. Our goal is to provide and maintain an excellent physician-patient relationship. Letting you know our office policy in advance allows for an effective flow of communication and enables us to achieve our goal. If you have any questions, please do not hesitate to ask a member of our staff. Arti Pediatrics may update this policy from time to time and will provide you with a copy of, or written notice of, any material change before it takes effect.
Limitations Required by Law: Nothing in this policy requires you to pay, and Arti Pediatrics will not seek to collect, any amount that applicable law prohibits us from billing to you. In particular: (1) if your child is a Medi-Cal or other government-program beneficiary, we will not bill you for covered services, missed-appointment fees, or other charges except as that program expressly permits; and (2) we will not balance-bill you for emergency services, or for covered non-emergency services provided by an out-of-network provider at an in-network facility, beyond your in-network cost-sharing. Where this policy conflicts with these protections or with your health plan contract, the law and your plan contract control.
Demographics and Insurance Updates: On each arrival, please check in at the front desk and present your current insurance card and photo ID. If you are new to the practice, or if your insurance or demographic data has changed, you will be asked to fill out our registration paperwork. These forms for registration are also available online and can be downloaded and completed prior to your visit. This is your verification of the correct insurance and consent to bill them on your child’s behalf. If the insurance company or information that you designate is incorrect, you will be responsible for payment of the visit.
Insurance Billing: As a convenience to our patients, Arti Pediatrics submits claims to your insurance carrier; all charges not covered by your insurance company are your responsibility. Parents/guardians are ultimately responsible for any charges, or portion thereof, that are your responsibility under your health plan, or that your insurance does not pay because coverage is unavailable, has been exhausted, or is denied for a reason not caused by the practice, except where prohibited by law or prior contractual agreement (see the Limitations Required by Law section above). Health insurance is a contract between you, your employer, and your insurance company. It is your responsibility to be familiar with the specifics of your insurance policy, including, but not limited to: vaccine and doctor visit coverage, referral/authorization requirements for specialty care, radiology, lab tests, and emergency and/or hospital care.
Not all services provided by our office are covered by every plan. Medical care and treatment for your child is dictated solely by medical necessity, and is not based on medical insurance coverage. Any service not covered by your plan will be your responsibility.
Office Visit/Sick Visit: An Office Visit (also called a "Sick Visit") is a non-routine visit for a specific health problem, question, or concern. This visit is problem-oriented and meant to address a specific health question. Insurance may require us to either (1) collect a copay at the time of the visit for these appointments, and/or (2) apply charges for the visit to Deductibles/co-insurance per insurance requirements.
Well Child Visit: Well child visit is preventive visit which is mostly covered by the insurance but there may be components that may require the patient to pay a separate Co-Payment/Co-Insurance or have additional costs applied to their annual Deductible.
Co-Payment and Deductible: The patient/patient’s guardian is/are responsible for their Deductible and Co-Payment. A "Deductible" means the amount you must pay for covered health care services before your insurance plan begins to pay. A "Co-Payment" means a fixed amount that you pay for a covered health care service, as specified by your insurance plan, typically due at the time of service. Insurance Co-Payment is always due at the scheduled time of service.
Card on File: To make payment of the amounts you owe more convenient, Arti Pediatrics keeps a valid credit, debit, HSA, or FSA card securely on file for each family. Your card information is stored by our PCI-DSS-compliant payment processor; the practice does not keep your full card number in the office. By signing below, you authorize Arti Pediatrics to charge the card on file for amounts that are your responsibility after your insurance has processed the claim — including Co-Payments, coinsurance, Deductibles, Non-Covered Services, and the fees described in this policy (for example, missed-appointment and returned-check fees). We will charge the card on file only after your insurer has processed the claim and applied its share. For any balance over $50, we will send an itemized statement to the email or address on file at least seven (7) days before charging the card. You may request an itemized receipt for any charge. You remain responsible for reviewing your Explanation of Benefits (EOB) from your insurer and for promptly notifying the practice of any billing error or disputed charge so that we can review it and, if appropriate, correct it. You may withdraw this authorization at any time by written notice, subject to any balance then due; the practice may require another form of payment, or decline to schedule non-urgent services, if no valid card is on file. Keeping a card on file is voluntary and is not a condition of receiving medically necessary or urgent care, and we will not charge the card of a Medi-Cal or other government-program patient except as that program permits.
Insurance Card: If the patient forgets to bring their insurance card, then they will be asked to cover the service charges in the form of cash/check/credit at the time of service. Arti Pediatrics will be happy to bill the patient’s insurance if you provide us with a copy of the insurance card. A credit will be issued to the patient account when your health plan makes payments on the claim.
Change of Insurance: Any change to patient insurance, including change of patient address, needs to be communicated to Arti Pediatrics at least 48 hours before a scheduled appointment. Patient/patient’s guardian is/are required to pay upfront for the services rendered on that day if the new insurance information is presented on the date of the visit and cannot be verified in time.
Identification Card: Arti Pediatrics needs a current government-issued photo identification card on file. This can be a driver’s license, state identification card, or passport.
Non-Covered Services: If Arti Pediatrics provides services to your child/children that are not covered by your health plan, you will be held responsible for payment in full for those services. Your signature below constitutes agreement to pay for such services. It is your responsibility to know and understand your coverage no matter what type/form of plan you hold. Not all services are covered by benefits in all contracts. Contact your insurance company to find out what benefits are covered or excluded under your plan and which healthcare providers are within your network.
Missed and Cancelled Appointments: All late cancellations and no-shows will be billed $40.00 automatically, except where prohibited by your health plan or by law. We require a minimum of 24 hours’ (one full business day’s) notice in advance to avoid these charges. When siblings are booked together, Arti Pediatrics requires 48 hours’ (two full business day’s) prior notice. Missed and cancelled appointments represent a cost to us, to you, and to other patients of our practice who could have been seen in the time set aside for you. These notice requirements apply to business hours and weekdays, excluding holidays and weekends; if an appointment falls on a holiday or weekend, the 24-hour (or 48-hour) cancellation notice must be given by the last preceding business day. No missed-appointment fee will be charged to a Medi-Cal or other government-program patient. Multiple missed appointments may be grounds for dismissal from the practice.
Late Arrival for the Appointment: If you are late for an appointment, we will do our best to accommodate you. However, it may be necessary to reschedule your child’s appointment to a later time or, if non-urgent, to another day.
Appointment Reminders: As a courtesy, Arti Pediatrics sends out appointment reminders by email or SMS to a cell phone. We also send an email about the appointment the night before the appointment. Arti Pediatrics also makes calls to confirm appointments. If we are unable to reach you, the ultimate responsibility to remember the appointment is yours. You will be responsible for a missed appointment charge if an appointment is missed.
After Hour, Weekend and Holiday Appointments: After-hour appointments are scheduled by special arrangement. There may be occasions when this service is not available, such as technology failure or physician(s) unavailability. In that case, please call 9-1-1 or go to the nearest emergency room. If you are seen in the office or by e-visit, then Arti Pediatrics charges $40 for that service, which is not billed to insurance and is in addition to the service charged to insurance. After-hour charges do not replace Co-Payment/coinsurance or Deductible charges.
After Hours Advice: After-hours advice is available when the office is closed. This service is only for urgent health concerns. In case of emergency, please call 9-1-1 or go to the nearest emergency room. For any non-urgent concerns, Arti Pediatrics provides secure messaging via Patient Ally. There may be a charge of up to $40 for after-hours calls transferred to an advice nurse or a physician. This charge represents the cost we incur in providing this important service. This fee applies only if, and to the extent that, it is not reimbursed or covered by your insurance; if it is not a covered benefit of your plan, you will be responsible for the fee.
Waiting Time: We strive to minimize waiting time. However, emergencies and unexpected prolonged visits do occur and will take priority over a scheduled visit. We appreciate your patience and understanding. Please note that many factors contribute to providing the service to the patient. Some of these factors include small babies not cooperating with vitals, late arrival of patients, and calls from hospitals and specialist callbacks. We try our best to adjust the schedule, but there are times when this may not be possible.
Referrals: When this office makes a sub-specialist, radiology, or lab referral for you, it is your responsibility to verify whether a physician or facility is participating in your insurance network as a contracting provider and what benefits are covered under your plan, in order to obtain your maximum benefits.
Insurance Disputes: As a convenience to our patients, Arti Pediatrics submits claims to your insurance carrier. It may take a significant amount of time for claims to be processed. In case your insurance denies or rejects all or part of the service charge, those charges will be billed to the patient, and it is the patient’s responsibility to follow up with insurance and file for any reimbursement. One-time patients (like traveling patients) are required to pay upfront. Once the insurance claim is finalized, Arti Pediatrics is not obligated to rebill the insurance on your behalf.
Billing for Your Newborn: If the patient is a newborn, parents please make sure to add your child to the insurance. This will expedite the billing for the services. If this is not done within two weeks from the date of birth of the child, then Arti Pediatrics will bill the patient directly and parents would need to file for reimbursement with insurance.
Past Balance Due: Once your insurance company has made a payment, your portion will be billed to you and is due within 30 days of the date of the statement. An administrative fee of $20.00 will be applied to any unpaid balance of $50.00 or more that exceeds 30 days past due for every billing statement sent to you. This administrative fee is charged to reimburse the practice for the actual additional billing and administrative costs of servicing a past-due account; it is a reimbursement of those actual costs and is not a penalty or liquidated damages, and it will not exceed those costs. Your account may be turned over to a collection agency if your unpaid balance exceeds 90 days. Arti Pediatrics reserves the right to not provide subsequent services unless the past due balance is paid; provided that we will not withhold emergency or urgent care, care we are required by law to provide, or care to a Medi-Cal or other government-program patient, and any decision to discontinue care will follow the Patient Termination process below.
Past Balance Due: Once your insurance company has processed the claim, your portion will be billed to you and is due within 30 days of the date of the statement. An administrative fee of $20.00 will be applied to any unpaid balance of $50.00 or more that exceeds 30 days past due for every billing statement sent to you. This administrative fee is charged to reimburse the practice for the actual additional billing and administrative costs of servicing a past-due account; it is a reimbursement of those actual costs and is not a penalty or liquidated damages, and it will not exceed those costs. Your account may be turned over to a collection agency if your unpaid balance exceeds 90 days. Arti Pediatrics reserves the right to not provide subsequent services unless the past due balance is paid; provided that we will not withhold emergency or urgent care, care we are required by law to provide, or care to a Medi-Cal or other government-program patient, and any decision to discontinue care will follow the Patient Termination process below.
Payment Plans: Arti Pediatrics may, in its sole discretion, offer a payment arrangement for an outstanding balance, but is not obligated to do so. Any payment arrangement must be agreed to in writing and does not change your underlying obligation to pay the full balance.
Divorce/Separation: A divorce decree is a legal agreement binding only upon the two parties who made the agreement. Therefore, Arti Pediatrics is not a party to that contract. Both parents remain responsible for the child’s bills. Under California law, both parents owe a duty to pay for their minor child’s reasonable and necessary medical care, and Arti Pediatrics may seek payment from either parent as permitted by law. The person signing this policy also personally agrees to be responsible for these charges. Please notify our practice of divorce or separation and update any contact or mailing information. If your divorce or separation agreement includes restricted access to patient records, specific financial responsibility, or other specifications, please send that information in writing. Arti Pediatrics must have court ruling on file from both the parties.
Immunization Card Replacement: A charge of $10.00 applies for replacement cards.
School Forms: There is a $20 fee per request, which will be waived if the form is presented at the patient's routine well child visit. We will not fill out forms during Sick Visits/Office Visits. Arti Pediatrics needs a minimum of 5 business days to process these forms. If the request is urgent then additional fees of $20 is added to the form fees. Urgent forms will be completed within 2 business days. These timelines for urgent and non-urgent form completion are valid when no additional action as tb skin test, blood work or x-ray is required for completion of the form. Arti Pediatrics is not responsible for delay caused by 3rd party entities. This fee is for the work of completing the form and is due regardless of whether the school, camp,or other third party ultimately accepts the completed form.
Other Forms: There is a $20 fee per request. We will not fill out these forms during Sick Visits/Office Visits. Arti Pediatrics needs a minimum of 2 business weeks to process these forms. If the request is urgent then addition fee of $20 is applied and forms will be completed within 5 business days. These timelines for urgent and non-urgent form completion are valid when no additional action is required for completion of the form. These forms include the ITIN form, camp form, etc. This fee is for the work of completing the form and is due regardless of whether the school, camp, or other third party ultimately accepts the completed form.
Collections: If it is necessary to assign your account to a collection agency and/or an attorney, you will be responsible for the reasonable collection costs and attorney’s fees actually incurred and recoverable under applicable law. If any attorney fees or costs are recoverable under this policy, that right is mutual, and if you are the prevailing party you may recover your reasonable fees and costs on the same basis. Consistent with California law, Arti Pediatrics and its agents will not report medical debt to consumer credit reporting agencies. In compliance with California SB 1061 : “A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable.”
Returned Check Fee: For any returned check, Arti Pediatrics will charge a fee of $25 for the first returned check (and $35 for each subsequent returned check), in addition to the original amount of the check. This charge covers our bank fees as well as additional processing and billing costs.
Payment Reversals (Chargebacks and ACH Returns): If a payment is later reversed — for example, through a credit-card chargeback, an ACH return, or a similar electronic payment reversal — the reversal does not extinguish the underlying financial obligation. The reversed amount remains due, and Arti Pediatrics may re-bill the amount, charge the card on file (subject to the Card on File section above), or pursue any other lawful means of collection, along with any applicable returned-payment fee described in this policy.
Medical Records: In accordance with state and federal law, and with some limited exceptions, Arti Pediatrics will allow parents or legal guardians to inspect a minor patient’s medical records within 5 business days upon receipt of a written request. For copies of records, Arti Pediatrics will provide copies within 15 days upon receipt of a written request. Arti Pediatrics charges a cost-based fee for copying medical records of $0.25 per page ($0.50 per page for records copied from microfilm), plus reasonable clerical costs and the actual cost of any electronic media (such as a USB drive or CD/ROM) if you request records in that form, or the amount permitted under HIPAA, whichever is less. Patient immunization records and growth charts are provided digitally free of charge.
Requests to forward records to other providers will be subject to the same cost-based fees outlined above. Please allow 10–14 business days for transfer of records.
Please note that patients over the age of 18 may request to inspect or receive a copy of their medical records, as noted above. Additionally, minors who are legally able to consent to treatment under California law - such as treatment or counseling related to birth control/family planning, pregnancy, sexually-transmitted diseases, outpatient mental health services (age 12 and older), substance abuse treatment, or sexual assault - may request records related only to that treatment. In both situations, parents or guardians will not be provided with any information or records unless the patient signs an authorization for the release of protected health information.
For records needed to support a claim or appeal regarding eligibility for certain public benefit programs, with some exceptions, patients and parents/guardians are entitled to one copy of relevant medical records at no cost. Please contact us if you require records to provide to a public benefit program.
Sharing Records for Treatment: We share medical records with other health care providers to allow and promote continuity of care among providers.
Voicemail and Text Notifications: As a service to our patients, Arti Pediatrics provides courtesy appointment reminder calls/texts and possibly other important calls that may be placed. The information may include protected health information. By initialing below, you consent to receiving such calls/texts at the phone number(s) you have provided to us. You may revoke this consent at any time by notifying our office by any reasonable means.
Electronic Prescriptions (E-Prescribing) and Online Access to Medical Records: I voluntarily authorize Arti Pediatrics to allow e-prescribing for prescriptions, which allows health care providers to electronically transmit prescriptions to the pharmacy of my choice, and to review pharmacy benefit information and medication dispense history, as long as a physician/patient relationship exists or until I withdraw my consent. Arti Pediatrics uses Patient Ally as a patient portal to share and communicate with patients. Your use of Patient Ally is subject to Patient Ally's own terms and conditions, available on the Patient Ally website; those terms are a separate agreement between you and Patient Ally, and Arti Pediatrics is not responsible for Patient Ally's terms or any changes to them.
Patient Termination: Arti Pediatrics values its patient relationships and wants to protect all patients’ rights. We only terminate patient relationships with cause and after careful consideration. Reasons for termination include: repeatedly not showing for scheduled appointments, not complying with recommended medical care, being hostile or abusive to staff, and repeated failure to communicate with the practice regarding an outstanding balance after reasonable billing efforts. Except in cases of abusive or threatening conduct, we will give you reasonable written notice before terminating care and will remain available to provide emergency and urgent care for a reasonable period (generally at least 30 days) so that you can arrange care with another provider.