Thank you for trusting Chisholm Trail Pediatrics to partner in your health care. This financial agreement should answer questions regarding patient and insurance responsibility for services rendered. Please read this agreement, ask us any questions you may have, and sign in the space provided.

Insurance

Your insurance coverage is a contract between you and the insurance company, and it is your responsibility to know your insurance benefits. As a courtesy, we will bill both your primary and secondary insurance companies. We will submit your claims and assist you in any way we reasonably can to help get your claims processed. In order to do this, we must receive all the information necessary to bill. If the information is not supplied, you will be billed, and payment in full will be your responsibility and will be expected within 30 days of receipt of statement.

Patient Responsibility for Payment

You are responsible for payment of any co-payment, co-insurance, deductible or service not covered by your insurance on the date of service. If you do not have insurance, you are responsible for payment of all services. Co-payments are due at the time of service. Patient due balances noted on your monthly statement are due within 30 days of receipt. Charges for minor children will be billed to the parent with whom the child resides. We will bill appropriate insurance if all required information is provided. We will not bill or contact a non-custodial parent on behalf of the custodial parent. New patients without insurance, or if insurance coverage cannot be verified, are required to pay at the time of service. The adult accompanying the minor child is responsible for 100% of payment at time of service.

Reschedule/No Show/Cancellation

In the event of a booked appointment needing to be rescheduled, please notify us up to 2 hours before the scheduled appointment. If the appointment is cancelled within the 2 hour window leading up to the appointment, there will be a $35 fee applied to your account. In the event of a no show/call for the scheduled appointment, there will be a $35 fee applied to your account. The company will make every attempt to provide appointment reminders to families, however, failure to receive the reminders does not excuse a no show.

Payment Options

We understand that financial circumstances vary from patient to patient. If you are unable to pay your patient due balance in full, you must call our business office at (512) 930-4776 to make payment arrangements.

Non-Payment

Failure to pay may result in your account being referred to a collection agency, which may affect your credit. If you account is referred to an outside collection agency, there will be a fee of 30% which will be applied at the time of referral. Non-sufficient fund (NSF) checks will result in a $25 processing fee.

 

I have received this financial policy and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand that delinquent accounts may be referred to a collection service. If it becomes necessary to send my account to a collection service, I agree to pay the additional 30% fee.

If you are registering multiple children, you can add them below.  

Address (if different from above):

I certify that the foregoing information is true and correct and I agree to pay all charges incurred for medical and professional services provided by Chisholm Trail Pediatrics at the time of service. If insurance is filed on my behalf, I will be responsible for all expenses incurred if insurance does not pay within 90 days. I authorize the release of information to process insurance claims and payment benefits to Chisholm Trail Pediatrics.