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 charges for these services. 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.
I do by hereby authorize Reston Town Center Pediatrics to apply for benefits on my behalf for services rendered. I authorize the release of any medical or other information for the purpose of providing care or securing payment for services rendered. I authorize direct payment of medical benefits directly to Reston Town Center Pediatrics.
I understand and agree that I am financially responsible for any charges not covered by my insurance carrier for services provided by Reston Town Center Pediatrics including but 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 responsibility 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 that if I wish to discuss issues beyond the scope of the routine exam during your Well Visit, your insurance company requires you to pay a co-pay, deductible or co-insurance for the Well Child Check.
I understand and agree that fees may be assessed for Well Check appointments cancelled less than 24 hours from the appointment time and no-shows. The fee will be billed and payable upon receipt.
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 a 1.5% late charge per month on the unpaid monthly patient balance.
Acknowledgement of Privacy Practices
I understand that the patient’s health information is private and confidential. I understand that Reston Town Center Pediatrics works 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 has a detailed document called the “Notice of Privacy Practices”. The document 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 Acknowledgement.
This Notice of Privacy Practices contains a complete description of my privacy/confidentiality rights. These rights include, but are not 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. This 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. Vaccines are safe and effective in preventing diseases and their subsequent health complications. For the safety of all our patients, families, and staff, we require all our patients to receive all recommended vaccines by age 2.