Patients with Insurance
Are responsible for decutibles, co-pays, non-covered services, coinsurance and items considered "not medically necessary" by your insurance company. Please pay co-payments and coinsurance amounts as services are rendered. The remaining balance should be taken care of within one (1) month of notice from the insurance company. If you or your insurance carrier makes payment exceeding balance, reimbursement will be remitted.
Patients without Insurance
Are responsible to make payment for your care at the time services are rendered.
Patients with no Insurance card or New Insurance or Insurance we are unable to verify
Are resonsible to make payment in full foryour care at each patient visit. You must present your card at time of service per your insuranc ecompany. After we receive payment from your insurance company and or an explanation of benefits, you will receive the appropriate refund, if required.
Patients that have signed a Waiver
Are responsible to pay for the procedures that are listed o the waiver that the physician has agreed to perform and will not file a claim with Insurance.
Assignment
I assign the benefits from my insurance carrier to this clinic for the medical/surgical benefits I am entitled to.
Release of Information
I authorize Pediatrics After Hours and MEK Pediatrics, PLLC to release to my insurance carrier and its agents any information needed to determine benefits payable for related services.
I authorize Pediatrics After Hours and MEK Pediatrics, PLLC to copy and/or fax my child's/chidren's shot records and/or medical records at my request without a signed authorization.
Notice of Privacy Practice
My signature below indicates that I ahve received a copy of the "notice of Privacy Practices" from Pediatrics After Hours and MEK Pediatrics, PLLC and that I may discuss any questions I have regarding this notice with the designated Privacy Officer of Pediatrics After Hours and MEK Pediatrics, PLLC.
I have read and agree to the Financial Policy, Assignments and Release of Information paragraphs above.