Office Policies/Financial Policies Agreement
These are all of our financial and office policies. Please read carefully and retain this copy for your records.
As the patient’s guarantor, you understand and agree to the following:
You authorize care and treatment by RDV Sportsplex Pediatrics (aka Pro Star Pediatrics, PA) and the release of all information to insurance and third-party carriers and direct them to remit payments directly to us.
The guarantor or authorized person accompanying the child is required to pay at the time of services rendered. This includes any divorce or custody cases, regardless of who the decree or custody documents indicate makes payment. Payment may include any copays and / or coinsurances, non-insured patient services, and past due balances (over 30 days). If a copay is not paid at the time of service, a $5.00 fee will be assessed to the account.
All checks returned for insufficient funds, closed accounts, or any other reason will be subject to a $25.00 service charge. The amount of the check and the service charge must be paid in full within five business days by cash, credit card or certified funds. Thereafter, checks will no longer be accepted for services rendered.
We request a current insurance card and verify eligibility for every visit. However, you are responsible for knowing your insurance coverage and benefits, including well visits and immunizations. As a courtesy, claims are billed to your insurance carrier and they are allowed 60 days to make payment. All balances not paid by the insurance carrier after 60 days from the date of service become your responsibility, and it is also your responsibility to follow up with them. We will be happy to reimburse you for any payments made by you after your insurance company has paid in full.
If you have any changes to your insurance information and fail to notify us, RDV Sportsplex Pediatrics will not be responsible for timely filing denials if we did not receive the correct insurance information prior to or at the time of services rendered.
If you have a newborn, we will give you up to two weeks from the date of birth to provide proof of coverage. If you are unable to do so after two weeks time, you will be responsible for any previously accrued balances and will have to pay out of pocket until proof of coverage is provided. Proof of coverage includes a letter from the insurance company, a hard copy of an insurance card with your child’s name on it, or a temporary card with your child’s name on it printed from the insurance company’s website. We will no longer accept a parent’s insurance card as proof of coverage.
If we are unable to verify your insurance at the time of your appointment, you can either pay out of pocket for the visit or reschedule to another day.
Self-pay patients who have previously been established with the practice will receive a 20% discount off of the exam if there are no outstanding balances and payment is made in full at the time of service.
If your account is referred to collections, you will be responsible for all attorney’s fees and collection expenses. A monthly late fee of up to 10% of the total balance will be charged to past due accounts over 90 days.
At each well checkup, you will receive a copy of your child’s immunization record and physical form, and any additional form you bring with you (such as sports physical forms, WIC forms, school medication administration forms, etc.) free of charge. If you request these forms or any other forms at any other time, they will be ready in 3 business days free of charge. In order to accommodate patients that need forms by the following business day, there is a $25.00 convenience fee for rush requests.
Under no circumstances will the doctors be interrupted from seeing patients during business hours to sign any forms.