PATIENT REGISTRATION

I realize verification of insurance coverage is my responsibility. In the event the listed medical service is not covered by my insurance, I agree to be financially responsible for the charges for these services. If my account is assigned to a collection agency, I agree to pay all agency fees, court costs, and attorney fees. I understand that all accounts with a balance over 30 days will be assessed at 1.5% late charge per month on the unpaid monthly patient balance. I do hereby authorize Reston Town Center Pediatrics, to apply for benefits on my behalf for services rendered. I request payment to be made directly to Reston Town Center Pediatrics. I verify the information reported regarding my coverage is correct and further authorize the release of any necessary information for any claim to my insurance company.

Furthermore, I hereby give permission for my child to receive medical care at Reston Town Center Pediatrics in case of an emergency in the event I cannot be reached.

Financial Consent

I authorize Reston Town Center Pediatrics to submit each visit to my insurance company on my behalf. I authorize the release of any medical or other information for the purpose of providing care or securing payment for services rendered. I authorize payment of medical benefits directly to Reston Town Center Pediattics.

I understand and agree that I am financially responsible for any charges not covered by my insuance carrier for services provided by Reston Town Center Pediatrics including buit not limited to: co-insurance, copayment, and/or deductibles and agree that I am to pay any of these non-covered charges at the time of service.

I also understand and agree that if my insurance company subsequently notifies Reston Town Center Pediatrics that my child is not covered as of the date of service, has no well coverage, has exceeded well-child coverage, or service provided is a non-covered service, I am to pay in full the amount not covered upon receipt of the patient statement.

I understand and agree that administrative costs including but not limited to: form completion, medical letters of necessity and/or copies of medical records will incur a charge that is the reponsibility of the parent/guardian and cannot be submitted to my insurance carrier. I understand and agree to pay these charges either up front or upon receipt of the patient statement as dictated by office policy.

I understand and agree that fees may be assessed for appointments cancelled less than 24 hours from the appointment time and no show appointments. The fee will be billed and payable upon receipt.

Should the account be referred to an agency for collection, I will pay resonable fees and collection expenses, and I understand that all delinquent accounts bear interest at the legal rate.

Acknowledgement of Privacy Practices

I understnd that the patient's health information is private and confidential. I understand that Reston Town Center Pediatrics works very hard to protect the patient's privacy and preserve the confidentiality of the patient's personal health information.

I understand that Reston Town Center Pediatrics may use and disclose the patient's personal health information to help provide health care to the patient, to handle billing and payment, and to take care of other health care operations.

Reston Town Center Pediatrics has a detailed document called the "Notice of Privacy Practices". It contains more information about the policies and practices protecting the patient's privacy. I understand that I have the right to read the 'Notice" before signing this Acknowledgment.

Withing this Notice of Privacy Practices is contained a complete description of my privacy/confidentiality rights. These rights include, but aren't limited to, access to my medical records; restrictions on certain uses; receiving an accounting of disclosures as required by law; and requesting communication be by specified methods of communications or alternative location. The Notice of Privacy Practices may be updated periodically.

 

Acknowledgement of Vaccine Administration Policy

I understand that Reston Town Center Pediatrics will administer vaccines in accordance with the American Academy of Pediatrics Guidelines. I also understand that I will be given information about these vaccines and the opportunity to discuss them prior to administration.