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.