We are dedicated to providing the best possible care and service to your child and regard your complete understanding of your financial responsibilities as an essential element of their care and treatment.
Patient Information: We appreciate you completing all patient registration forms accurately and in their entirety. These documents must be updated annually for each individual patient. Insurance cards are required prior to the time of service. If your insurance information is not provided at the time of service, and we are unable to bill the charges within the time limits set by your insurance carrier, the balance will become the guarantor’s responsibility. Change of Insurance/Change of
Account Information: Please notify the office as soon as possible of all account changes, including co-pay amounts, insurance updates, and a change of mailing address. If the account holder does not notify the office of these changes promptly, the assigned account holder becomes responsible for all charges.
Newborns: Please contact your insurance as soon as possible after the birth of your child. Most health plans allow 30 days to add your newborn, otherwise you may have to wait until an open enrollment period to add the child. If, after 30 days, we are unable to verify the child has been added to the policy, the balance will become guarantor responsibility.
Billable Services: In–office visits, Telemedicine visits. Telephone calls and Portal Messages will be billed in accordance with your insurance carrier.
Payments: Our practice participates with many major insurance plans. Billing insurance does not guarantee payment and it is your responsibility to confirm that we participate with your plan. We will submit claims as per our agreement with your insurance company.
Copayments/Deductibles/Outstanding Balances: If your insurance includes a co-payment for a visit, payment is expected at the time of the visit. You are also responsible for any deductible or coinsurance. It is your responsibility to know the benefits your plan provides.
Managed Care: If you have an HMO plan, please assign one of the physicians in our practice as your child’s primary care physician (PCP) PRIOR to your visit. If we cannot confirm that one of our providers is listed as the PCP, we will ask that the appointment be rescheduled.
If you are enrolled in a managed care insurance plan (i.e., HMO), your plan may require a referral from your PCP before seeing a specialist. NO retroactive referrals will be given.
Out of Network: If we DO NOT participate with your insurance or you DO NOT have proof of insurance at the time of check-in, you will be considered out of network and therefore become a self-pay patient. Westside Pediatrics does not bill out-of-network insurance plans. Full payment is expected at the time of service.
Self-Pay Accounts: A credit card on file is required for all services. Charges for each visit will be billed to your credit card at time of service.
Payment Plans: Westside Pediatrics understands that full payment may not be possible in certain circumstances. As a courtesy, we may offer the assigned account holder a payment plan. Payment plans are approved on a case-by-case basis and may be discussed with our billing account manager or office manager. Families with a payment plan must be in full compliance with the conditions of the agreement at the time of any visit. Failure to make scheduled payments, or not paying the balance in full, may result in the office being unable to schedule future visits.
Annual Practice Fee: Westside Pediatrics has an annual practice fee for all patients. Prompt payment is expected. Our annual practice fee is nonrefundable.
Missed Appointments: Cancellations are required 24 hours prior to the scheduled appointment. A “no show” fee of $75.00 will be applied to any missed or late canceled appointment.
Preventive Care vs Sick Visits: When children are scheduled for preventive care (well child check-up), it is YOUR responsibility to verify your insurance benefits before the appointment. If your child is sick on the day of the well child visit, we may see your child for a sick visit and reschedule the well check. Your clinician may determine that the child can be seen for both a well and sick visit during the same encounter. In this circumstance, you may be subject to a copay or deductible for the sick portion of the visit.
Outstanding Balances: If you have a personal balance on your account, a monthly statement will be sent. Unless authorized in writing, payment is due upon receipt of the statement or within 30 calendar days. Patients with an outstanding balance beyond 60 days will be asked to make payment arrangements prior to scheduling future appointments.
Returned Checks: A $50.00 fee will be charged for any checks returned for insufficient funds and you will be asked to pay by cash or with credit card for future visits.
Collections: Delinquent accounts are balances that have not been settled within 90 days of the original statement. If an account is assigned to a collection agency, a fee of $150.00 will be added to the delinquent balance. Any discounts will be added back to the balance and the full amount will be given over to the collection agency. The second time a family is assigned to a collection agency it is at our discretion to dismiss the family from the practice. You will be given 30 calendar days to find a new health care provider.
Credit Card on File: Westside Pediatrics recommends that a credit card be kept on file for balances that may be incurred on the account. Credit Card on File will be used to pay account balances after insurance adjudication.
Please contact us at 212 874-4500 or at email@wppc.pcc.com if you have any questions.
Review and consent of this policy are required prior to services rendered.
My signature below certifies that I have read and consent to the outlined policies and procedures in the above financial policy agreement.