Financial Responsibility Form

You must review and sign this Financial Responsibility Form which will be kept in your patient file.  References to "you" or "your" in this Form mean:

(A)    For a minor patient: the parent or other adult guarantor who signs this Financial Responsibility Form; or

(B)    For an adult patient: the person who signs this Financial Responsibility Form on his or her own behalf.

This Financial Responsibility Form applies to all services provided to the patient on or after its date, unless and until modified in writing by CCH Pediatric Clinic P.C. or you sign a new Form provided by CCH Pediatric Clinic P.C.

 

CCH Pediatric Clinic P.C. (“CCH”) adheres to the American Academy of Pediatrics standard of care for all evaluations and treatments. If your provider determines that a service or evaluation is medically necessary, it will be performed regardless of insurance coverage, and you will be responsible for any non-covered costs. Because insurance plans vary, CCH cannot guarantee coverage for specific services. Providers base medical decisions on the best standard of care, not on individual insurance benefits.

You are responsible for providing CCH with accurate and updated information, including insurance cards and contact details. Any changes must be reported to CCH promptly.

Payments & Insurance

• Co-pays and deductibles are due at the time of service. If you are unable to pay, your appointment may be rescheduled.
• If you are uninsured or out-of-network, payment is required at the time of service unless CCH has approved other arrangements in advance. CCH accepts Visa, MasterCard, and Discover.
• If your insurance requires a referral or prior authorization, you must provide it before or at your appointment. Without it, your visit may be rescheduled, or you must be prepared to pay in full.
• As a courtesy, we will attempt to file your insurance, but you are responsible for any co-insurance, deductibles, or non-covered services, which must be paid within 60 days of claim processing.
• If you cannot pay in full, you must contact CCH’s billing office to arrange a payment plan. Any payment plan will require regular minimum monthly payments (for example, minimum payments of $50 per month). You acknowledge that any payment plan is not an extension of credit. Failure to maintain your minimum payment requirement will result in your account being sent to collections.
• CCH does not intervene in disputes related to divorces, legal separations, or third-party litigation, and such matters do not exempt you from timely payment.
• If you fail to update your address or contact information and CCH is unable to locate you, CCH will immediately refer your account to collections.

Billing & Collection Process

• You will receive an initial statement requesting payment. If you are unable to pay the amount in full, please contact CCH’s billing team to make payment arrangements.
• Statements will be sent on a monthly basis for balances of $3.00 or more.
• If the initial statement is unpaid, a second (past due) notice will be sent.
• If no payment is received, a final notice will be sent with a 15-day deadline before your account is referred to a collection agency.
• If no payment is received within the 15-day deadline, your account will be turned over to a collection agency and all payments must be made to the agency. If your account has been turned over to collections, you will have 30 days to find a new provider and you will no longer receive treatment from CCH except under the following conditions: you have made specific payment arrangements and any visits during the 30-day period will be on a cash-only basis and payment must be made in full before receiving treatment.

Lab Services

If your insurance requires labs to be processed at a specific facility, you must inform staff at the time of service. If not, you will be responsible for any charges. Lab specimens collected by CCH are processed at Columbus Community Hospital, unless other specific arrangements have been made.

Communication Consent

By providing your contact information, you expressly consent to receiving calls, texts, and emails (including automated and pre-recorded calls) from CCH and its agents regarding appointments, billing, and collections, including to any cellular telephone numbers you provide, and you acknowledge that such communications may be subject to standard message and data rates from your carrier. If your phone number changes, you must notify CCH immediately.

No-Show Policy

• 24-hour notice is required for cancellations or rescheduling.
• Missed appointments without notice incur a $25 no-show fee, which is not billed to insurance.
• Three (3) no-shows may result in dismissal from the practice.
  CCH understands emergencies happen and will review situations as needed.

Insurance & Claim Processing

• CCH will attempt to code claims for your services and handle them as follows:
  • If CCH has a contract with your insurance company, CCH will file claims in accordance with that contract.
  • If no contract exists, CCH will attempt to file claims as a courtesy, but you remain responsible for any unpaid balance, including uncovered services or disputed evaluations.
• If your insurance company does not process your claim within 45 days, CCH will attempt to follow up with your insurance company for status updates on your claim.
• If a claim is processed incorrectly, CCH will attempt to resolve the issue in a timely manner.
• Overpayments will be handled per CCH’s Patient Refund Policy.
• CCH will answer all account inquiries honestly and work to resolve any issues promptly.

Additional Terms

• CCH reviews fees annually based on Health Care Finance Administration and American Medical Association guidelines. CCH’s fees are adjusted to align with acceptable ranges of CCH’s contracted, and most other, insurance company ranges.
• Modifications to this policy require approval from CCH’s Financial Controller, Practice Administrator, or their designee. Nothing in this paragraph precludes CCH from settling legal disputes or pursuing CCH’s rights regarding medical liens or assignment of benefits.
• Signing this form does not reduce the liability of any other responsible party to CCH.
• For questions about CCH’s financial policy, please contact CCH at 402-564-7200.