Professional services are charged to the patient, not the insurance company. This office does not accept responsibility for collecting your insurance claim, or for negotiating a settlement on a disputed claim.

I hereby authorize The Children's Clinic of Conway and Greenbrier to furnish information to insurance carriers concerning my child's illness and treatments and I hereby assign to the physician all payment for medical services rendered by insurance.

The patient will be responsible for all co-payments, deductibles, and co-insurances which are due at the time of service.

It is the patient's responsibility to keep us updated on correct insurance information. If you do not tell us about changes or pending changes, you could incur charges that may or may not be covered by your insurance.

We verify most insurances as a courtesy, however, there is no way we can determine all your benefits so we cannot guarantee what may or may not be covered by your plan until the claim is processed. Examples may include:

• Well Child exams and immunizations. Not all plans cover these. Some may only cover to a certain age and some only cover up to a certain dollar amount. Some plans may pay 100% and others may still charge copay. Please be familiar with your plan to know what may or may not be covered as you will be responsible for any charges incurred.
• Some procedures, such as laceration repair and wart removal may be processed at a different benefit level other than just a routine office visit and could be subject to deductibles and co-insurances.
• Some plans exclude certain diagnoses. There is no way we can make that determination when we check eligibility, and you may be responsible for those visits.
• Diagnoses such as ADHD may be covered by mental health benefits and could be subject to deductibles.

Statements are mailed out weekly. Payment is due within 15 days of receipt. Any balances over 90 days with the patient receiving at least 3 statements with no activity can be turned over for collections and you could be discharged from the clinic.

We do not get involved in separated and divorced parents' financial obligations. We will send the statement to whichever parent is listed as the guarantor and we hold both parents responsible for any outstanding balances.

*The signature below covers the above authorizations and consents for the patient listed below.

I authorize The Children's Clinic of Conway & Greenbrier to store my credit card information on file. I authorize The Children's Clinic to use this card for each visit up to a maximum of $250.

*The signature below covers the above authorizations and consents for all patients listed on the first page.