Financial Responsibility Policy

Tosa Pediatrics encourages you to familiarize yourself with our Financial Policy and your insurance benefits. Your insurance policy is a contract between you and your insurance company; therefore, YOU ARE ULTIMATELY RESPONSIBLE FOR PAYMENT of all charges.  It is YOUR RESPONSIBILITY TO RESOLVE DISPUTES between you and your insurance company regarding deductibles, co-payments, coinsurance, covered charges, secondary insurance, or any other patient responsibilities indicated by your insurance carrier. 

Services Charged:  Any and all services and products provided by Tosa Pediatrics will be charged to your account.  These services include any and all preventative care (well/health maintenance/sports physical visits and immunizations), illness/sick visits, visits for behavioral health, visits for medical management, and visits for chronic disease management, REGARDLESS OF WHETHER THE VISIT OCCURS IN PERSON, VIA VIDEO, VIA AUDIO ONLY, VIA TEXT OR MESSAGING PLATFORM, OR VIA EMAIL. Charges are generated regardless of severity and regardless of who provides the service, including, but not limited to a physician, physician assistant, nurse practitioner, registered nurse, dietitian, occupational therapist, behavioral health specialist, lactation consultant.  MANAGEMENT OF ACUTE OR CHRONIC HEALTH ISSUES OR MEDICATIONS DURING A PREVENTATIVE VISIT WILL INCUR CHARGES above and beyond those incurred by the preventative visit itself.  Customary charges are incurred for after-hours care and for “on-call” phone management at the discretion of the provider.  Charges are incurred for no-show / less than 24 hrs notice of missed appointments.

Individual/Group Insurance:  While Tosa Pediatrics can assist in determining “in-network” status, it is ultimately YOUR RESPONSIBILITY TO CONFIRM NETWORK STATUS; NOT THE RESPONSIBILITY OF OUR STAFF.  Not doing so may result in your responsibility for “out-of-network” charges. As a courtesy, Tosa Pediatrics agrees to file claims for services rendered with your insurance carrier. YOU ARE REQUIRED TO PROVIDE ACCURATE INSURANCE INFORMATION at every visit regardless of whether or not our staff request it. You are responsible for payments to Tosa Pediatrics for the following:

1. Any co-payment as set by your insurance carrier at the time of service
2. Any unsatisfied deductible 
3. Any amount your insurance carrier deems your responsibility
4. Any amount considered non-covered by your insurance carrier
5. Any charges related to termination of coverage

If Tosa Pediatrics has not received payment from your insurance carrier within 60 days from the date of service, you may be expected to settle any balance in full.  You are responsible to confirm all charges are settled, whether by you or your insurance carrier.

You are accountable for responding to any request from the insurance company for further information.  Not doing so will result in a claim denial and you will be responsible for payment.  

Insurance Authorization/Release:  You authorize Tosa Pediatrics to release any and all information necessary concerning my diagnosis and treatment for the purpose of securing payment from my insurance company; and thereby authorize payment of the insurance benefits directly to Tosa Pediatrics for any and all services rendered. 

Types of payment accepted: Tosa Pediatrics accepts cash, personal checks, Visa, MasterCard, Discover and American Express.  A 3% SURCHARGE WILL BE APPLIED TO ALL CREDIT CARD TRANSACTIONS.  No surcharge is applied to the use of debit cards nor HSA cards.  There is a $30.00 SERVICE CHARGE FOR RETURNED CHECKS.

No Insurance Coverage: Tosa Pediatrics offers a self-pay discount when payment is made within 30 days of services rendered.  You are financially responsible for all charges incurred for “self-pay” services provided. 

Liability: Services incurred resulting from injury or accident are considered your responsibility.  It is YOUR RESPONSIBILITY TO ENSURE THAT TOSA PEDIATRICS IS PAID PROMPTLY regardless of pending disputed or litigated claims.  Tosa Pediatrics is unable to file claims to a third-party insurance carrier.

Collections and Discharge from Care: Should there be any remaining balance on your account, you agree to pay for services rendered.  ACCOUNTS UNPAID GREATER THAN 90 DAYS WILL BE OUTSOURCED TO A COLLECTION AGENCY. Once  your account has been placed in collections, YOUR CHILD MAY NOT BE SEEN UNTIL THE BALANCE IS PAID IN FULL AND MAY RESULT IN DISCHARGE from Tosa Pediatrics.  You have the option to set up payment arrangements, the details of which may be changed at the sole discretion of Tosa Pediatrics.

Copies of Records:  You will be charged to the extent allowed under WI Statute for administrative costs incurred in reproducing medical records for purposes of personal use or transfer of care.

Summary of (not a substitute for) Financial Responsibilities noted above.

1. I am responsible for payment of charges.
2. It is my responsibility to resolve insurance disputes.
3. I am responsible for charges incurred for any and all services provided regardless of severity, provider, and means of communication including phone/text/email.
4. I understand that services provided above and beyond strictly preventative care services will incur additional charges even if discussed at a preventative visit.
5. I will be charged for no-shows and less than 24-hr notice of missed appointments.
6. I am solely responsible for determining my insurance in-network providers.
7. I accept all consequences of not providing accurate insurance information.
8. If Tosa Pediatrics fails to receive insurance payments, I am personally responsible for the charges.
9. I accept the 3% surcharge on credit card transactions and $30 returned check fees.
10. I am responsible for payment of charges associated with accidents despite any pending litigation.
11. My account will be sent to collections and my family will be discharged from Tosa Pediatrics if my financial responsibilities are not met within 90 days.
12. Copies of records will be charged to the extent allowed by WI statute.

I HAVE READ AND RECEIVED A COPY OF  THE ABOVE FINANCIAL RESPONSIBILITY POLICY IN ITS ENTIRETY.  I AGREE TO THE TERMS SET FORTH AND CLEARLY UNDERSTAND MY FINANCIAL RESPONSIBILITIES FOR ALL SERVICES RENDERED BY TOSA PEDIATRICS.