Even if you have a health insurance plan, you understand that you are responsible for paying for the cost of care you or your child receives.

We verify eligibility of insurance at every visit and ask you to produce an insurance card at each visit. If your plan requires a selected Primary Care Provider (PCP), you must select our practice before being seen.

While Bay Haven Pediatrics accepts many insurance plans, the variety of plans and their features make it impossible for us to know the details of your insurance plan. You are responsible for the details of your insurance plan, including any co-payments, co-insurances, deductible plans, and coverage details. You must notify us of any changes in your plan or your insurance carrier.

By signing this document, you are giving permission to Bay Haven Pediatrics to obtain payment directly from your insurance company for the services you receive. You are giving permission to your insurance company to pay Bay Haven Pediatrics directly. You are giving permission Bay Haven Pediatrics the legal right to claim payments from insurance companies for the services you receive.

Because of changes in insurance regulations and insurance plans, it is no longer accurate to say "all preventative services are fully covered." Please note your insurance may assess copays or coinsurance even during well visits for health screenings, for a child who is sick during a well visit, chronic care coordination, etc. Bay Haven Pediatrics provides care and screening based on the medical judgment of the medical providers, as well as the recommendations of the American Academy of Pediatrics ("AAP"). Bay Haven Pediatrics also follows the billing code best practices of the AAP. While we understand that some patients may be paying more out of pocket for certain kinds of preventative care, Bay Haven Pediatrics will continue to follow AAP guidance for insurance billing.

251 Najoles Road, Suite E, Millersville, MD 21108 * Phone : 410.729.0690 Fax : 866.531.7815
www.bayhavenpediatrics.com

By signing this agreement, you understand that you are responsible for paying for the cost of services at the time of your visit.

You must pay your copayment and account/family balance at the time of your visit. If you are unable to pay your account balance at the time of a preventative visit, we may reschedule you until you are able to make the copayment or account balance payment. We will not reschedule sick visits, but you are still responsible for paying for services. Please note the parent/guardian who attends the visit is required to pay the copayment and/or balance at the time of service or arrange pre-payment to be made by the responsible party before the visit.

If you have deductible and/or coinsurance associated with your insurance plan, then you must place a payment card on file with us. The card can be a credit/debit card, a Health Savings Account ("HSA") card, or a Flexible Spending Account ("FSA") card. Once we have made the claim to your insurance company and the extent of your benefit is determined, we will charge your card on file for the difference.

At this time Bay Haven Pediatrics accepts payment in the form of cash, debit/credit cards (include HAS or FSA) and personal checks. Any check returned unpaid will be assessed a $35 fee, and we may refuse to accept checks as payment after a returned check.

We understand that sometimes finances are difficult for families. If you are unable to pay your full balance, then Bay Haven Pediatrics will assist you to structure a payment plan. Payment plans will spread your balance owed over the course of up to three months. If you need more time in your payment plan, then you must contact the Practice Administrator with a proposal. Bay Haven Pediatrics has no obligation to agree to any payment plan.

If you do not have a payment plan and you have not paid your balance due for more than 90 days, Bay Haven Pediatrics will place you into "collection status." Accounts that are in collection status may be referred to a collections agency to collect on the balance owed. If a family is in collection status, then Bay Haven Pediatrics may choose not to see your child(ren) until the balance is paid in full. Bay Haven Pediatrics may dismiss you from the practice if you are in collection status.

251 Najoles Road, Suite E, Millersville, MD 21108 * Phone : 410.729.0690 Fax : 866.531.7815
www.bayhavenpediatrics.com

We understand that things happen in life and you may not be able to make a scheduled appointment.

We ask that you give us at least three (3+) hours' notice for cancellation. This notice allows us to schedule other patients for sick visits so we can care for another patient

If you do not provide three (3) hours' notice, Bay Haven Pediatrics will assess a missed appointment fee of $45. Multiple missed appointments or appointments cancelled without 3 or more hours' notice may result in dismissal from the practice.

We are pleased to offer a new digital pre-check-in process via Chadis. You will be able to complete all health assessments and screening questionnaires right from your smart phone or other device. You will receive an email with an invitation to Chadis. Please arrive 10 minutes early to any scheduled appointment if you are not able to pre-check-in via Chadis. Patients arriving more than 15 minutes late may be required to reschedule their appointment to the next available opening consistent with the type of appointment requested (which may not be the same day). Only acutely ill children will be offered to be worked into the providers' schedule later the same day.

251 Najoles Road, Suite E, Millersville, MD 21108  *  Phone : 410.729.0690  *  Fax : 866.531.7815
www.bayhavenpediatrics.com

There is a $10 fee associated with forms per child, including school, sport, daycare, camp, college and medication forms. We require 7 to 10 business days to complete the forms. We cannot accept any form that does not have the parent section filled out and included.

In the event your circumstances require completion of forms in less than 7 days we can offer an expedited service. The cost for the expedited service is $25 payable at the time the forms are presented, and you will receive your forms within 48 hrs. In addition, we will waive the fee if forms are presented during that child's well visit or sports physical. This does not apply to sick visits.

This document must be signed by a parent or legal guardian if the patient is legally a minor under the age of 18 or mentally unable to understand and sign this document.