I hereby authorize and consent to the examination/treatment of my child(ren) during the office and facility visits by the physician and clinical staff of Poole and Thomas Pediatrics. In addition, I give permission for the following person(s) to bring my child to Poole and Thomas Pediatrics in my absence and to act on my behalf in authorizing medical care and treatment.

Until we are notified in writing, Poole and Thomas Pediatrics will assume that a child’s biological and/or legal parents are both legal guardians who have access to treatment options and medical information for that child.

By my signature below I acknowledge that I have read and understand the information provided on this consent form. I understand the risk associated with the different methods of communication, especially e-mail and texting, and consent to the conditions, restrictions, and patient responsibilities as well as any other instruction that Poole and Thomas Pediatrics may impose.

Insurance
We ask that all our families that have insurance make sure their policies are active and to call or bring in any new insurance information prior to, or at the time of, any office visit. We bill all patients and families who have health insurance in accordance with the requirements of their health insurance coverage. In today’s complicated health insurance market, it is difficult for patients and families to understand how their insurance coverage works. We are obligated by law and by insurance contracts to code and bill for visits in accordance with the policies set forth by each health insurance carrier. Insurance company contracts determine how we must apply copays, coinsurance, and deductibles, and require that we collect from our patients that cost-sharing component. We require all families and patients to pay any and all fees due and payable on the date services are rendered.

Newborns
Insurance companies generally only allow 30 days to add your newborn to your insurance plan. Please call ASAP to get this done. Once you receive your child’s card, please provide us with a copy. If you fail to add your baby to your plan, you will be financially responsible for all visits.

Patients Without Insurance Coverage

We are happy to work with families that prefer to pay directly for services or do not have insurance. For such patients we must collect payment at the time of service.  We provide vaccines free of charge through the Vaccines for Children (VFC) program. However, each vaccine administration cost is $19.93 per vaccine and must be paid at the time of service.

Poole and Thomas Pediatrics does NOT accept Cost Share plans as these are not insurance policies. We will consider patients with this coverage to be self-pay and payment is due in full at the time of service. We will be happy to provide receipts for all services rendered that families can turn into their plan.

For all self/private-pay patients, you will be charged for care rendered at the time of service. Payment will be taken based on the information our front office staff has available to them at the time of the appointment (Good faith estimate). Once the provider completes documentation in the patient’s electronic health record, additional codes/fees may be incurred and billed to you during the next billing cycle. Should this occur, we are happy to provide an updated charge slip upon request. 

Divorced/Separated Parents and Custodial Agreements
PTPEDS does not get involved in disputes between divorced, separated or custodial parenting arrangements regarding financial responsibility for their child's medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree, custodial or other arrangement places that obligation on someone other than yourself. We are happy to provide receipts for paid medical bills for you as requested. Parental decision-making for divorced parents regarding medical care should be agreed on prior to any visits. As a practice, we will not interfere in these decisions, but additional visits may be required if timely agreements cannot be met at the time of service.

Yearly Registration
Registration will be updated every year at the first of the year. We will send out electronic registration in January.

If we do not have a current registration, we will reach out the week before your appointment to have this completed. If this is not updated prior to the appointment, parents will be asked to complete an electronic form upon check-in for their appointment.

Patient Portal

We require all patients to have a PTPEDS online portal for communication.  This allows us to communicate appointment information and allows parents/patient to request forms and medication refills. 

Billing and Vaccine Companies
Billing services are provided by PedsOne, located in Vermont.  For all of your billing questions please contact them at 1-866-371-6118.

Vaccine are provided and billed by VaxCare. We must have a current insurance on file that we are able to confirm through their online website. If we are unable to verify insurance or if the insurance is showing inactive, we request payment at the time of service for the full cost of the vaccines and administration. You may receive communication or billing from Vaxcare if your insurance does not cover vaccines or is found to be inactive.

Appointments
Well Check-ups are required
At PTPEDS, we feel strongly about children having routine check-ups. These visits allow us to monitor for growth, developmental, behavioral and academic issues so that we can identify them early, intervene, and treat them effectively. Per the American Academy of Pediatrics, children should receive preventative care at the following ages:

1month of age, 2mo, 4mo, 6mo, 9mo, 12mo, 15mo, 18mo, 24mo, 30mo, then yearly from 3-22 years of age.

We expect parents to follow these guidelines so that we can provide quality healthcare to our patients. Failure to do so may result in being discharged from our practice. Documents and school forms will not be completed for patients who are behind on well checks.

Screenings
We perform recommended screenings based on the patient’s age to detect any conditions that may need treatment. Most insurance plans cover these screenings and costs; however, some recommend the screening but push costs to the patient’s deductible/co-insurance. Some do not cover the recommended screening at all. It is a parent’s responsibility to understand which screening services are covered by your specific insurance plan.

Screenings 

·         Edinburgh Postpartum Screening

·         Ages and Stages Questionnaire (development screening)

·         MCHAT (Modified Checklist for Autism in Toddlers) at 18mo, 2yr

·         Spot Vison Screening 1yr – 5yr

·         Lead and TB exposure questionnaire

·         Hearing and vision screening

·         PHQ-9 Depression screen

·         GAD-7 Anxiety screen

Well Check-ups vs. Problem-Oriented visits
Well visits may reveal problem-oriented issues that require evaluation and management (for example, ear infections, ADHD concerns, Anxiety and Depression). Insurance company billing policies then prompt charges for both categories when there is an added diagnoses to the well appointment. While well checks/preventative services may not require a co-pay or deductible, problem-oriented services do. If you need further explanation about incurring additional fees for services provided during your visit, please speak with our billing team.

Chronic medical conditions require follow-up
Chronic medical conditions such as ADHD, asthma, depression, and anxiety require frequent follow up to ensure the best care possible for your child. Patients with ADHD need follow-up every 3-4 months once they are stable on their medication. Other chronic medical conditions need follow-up every 3-6 months once stable depending on the child’s care plan. Medications may not be refilled unless patients keep their follow-up appointments.

Vaccine Policy
Vaccinations are safe and effective in preventing diseases and health complications in children and adults. PTPEDS requires that all patients are immunized according to the current vaccine schedule recommended by the American Academy of Pediatrics and CDC. In order to protect our patients, we do not accept families who don’t vaccinate their children. Although recommended, covid and flu vaccines are not part of this requirement. If families have any questions about vaccines, they can speak directly with one of our providers.  If your family ultimately chooses not to vaccinate, we will ask you to find a clinic that better aligns with your wishes for your child.

Vaccines given to all patients at our office are inputted into the KYIR (Kentucky Immunization Registry) system, a service of the Kentucky Department for Public Health that allows individuals, parents and legal guardians to access official immunization records.

Medication refills

Please call the office 1 week prior to running out of a prescribed medication. Patients must be up to date on their well-check visits/med-check visits in order for prescriptions to be refilled without the patient being seen in the office.  Please allow 2 business days for these to be processed.

 CONTROLLED SUBSTANCE REFILLS

If requesting a refill for an ADHD medication we must have the patient’s Social Security # on file. Per laws in the state of KY, we are required to obtain a KASPER before medication can be prescribed or refilled. Patients must be seen every 3-4 months in order to have these prescriptions managed by our office. Medication refill requests must be submitted 1 week prior to running out.

Mutual Respect of Time
Providers at Poole and Thomas Pediatrics strive to stay on schedule. Although there can be emergency situations that prevent us from running on time, we pledge to provide quality care with minimal wait time to the best of our ability. In order to respect your time, we make the following requests:

·         Arrive early or on time for your appointments. If you arrive 10 or more minutes late, you will be asked to reschedule.

·         If you plan on having additional children seen at your appointment, please let us know in advance so we can better accommodate your family.

·         If you are running late, please call the office. We may be able to accommodate you with advanced notice.

·         Three (3) “no-show” appointments without notice from you in one year may result in dismissal from our practice.

·         New patients who no show without notice to their first appointment may not be scheduled for additional appointments.

Treatment of PTPeds Staff
We here at Poole and Thomas Pediatrics value our staff members and the pleasant work environment we have created.  We will not allow mistreatment of our staff or providers by patients or their parents.  We have a system in place to keep track of incidents of poor conduct and a family will be subject to dismissal from the practice for such behavior.  We are committed to treating our patients and their families with the same respect we are requesting.

Additional Fees

No-show/late fee: We have many patients in our practice and all are important to us. Missing an appointment without giving prior notice to the practice deprives other patients of the chance to take that appointment slot. Therefore, we require no less than 24 hours’ notice for all cancellations of pre-scheduled visits. If you cannot notify our office in a timely manner, a no-show fee of $35 will be charged to the patient’s account and must be paid before rescheduling.

Phone triage:
After hours, we offer a telephone triage consultation service that puts you in touch with a pediatric-trained triage nurse. Families will be charged for each triage call made ($16).
There are exceptions for advice given for infants less than 90 days old or where recommendations are given to immediately be seen by a healthcare provider.
Additionally, if a provider speaks with a parent directly after hours or on the weekend, the call will be billed to your health insurance.

Paperwork Requests
Please allow 2 business days for any paperwork to be processed and returned.  FMLA paperwork is extensive and time-consuming.  There is a $25 fee for our office to complete requested FMLA paperwork.

 

Poole and Thomas Pediatrics, PLC

FINANCIAL POLICY

EFFECTIVE January 1, 2024 

Thank you for choosing and entrusting Poole and Thomas Pediatrics for your child(ren)’s care. Drs. Poole, Thomas, Crowley, and Goodsell are dedicated to providing excellent care to your children at a fair and reasonable rate.  In order to provide this care, we have adopted the following financial policy.  We recognize that the cost of health insurance has increased; unfortunately, our costs to provide that care have risen significantly as well. 

It is our goal to eliminate future misunderstandings in regard to our billing and payment policies.  Our staff will be happy to discuss any fees or financial issues in advance or at the time of your visit. We participate with most major insurance plans.  While we will work with you to submit your claims to your insurance company, please note that ultimately your insurance is a contract between you and your insurance carrier. Each insurance policy is individual and it is your responsibility to understand your benefits, eligibility dates, and what is and is not covered by your plan. If claims are not paid within 90 days, the unpaid balance becomes the responsibility of the parent/guardian. We will make every effort to work with you to file insurance claims and resolve any outstanding balances in a timely manner.

Please be aware that you MUST provide updated demographic (address and phone numbers) and insurance information to our office. Up-to-date information is needed for both parents.  We must have a current copy of your insurance card and ID on file at all times. If your insurance changes, it is your responsibility to let us know as soon as possible, along with the effective dates of your new policy. If previous visits need to be re-filed to a different insurance, you must notify us immediately due to Timely Filing requirements by your insurance company. If you do not provide us with the correct insurance information at the time of the change, then your claims may be denied due to timely filing by your insurance and those claims would then become your financial responsibility. You will also be responsible for any denied charges due to incorrect information. 

Co-pays, Co-insurance and Deductibles will be expected at the time of service.  Private Pay Patients are expected to pay in full at each appointment and are given a discount at the time of service. If there is an outstanding balance on your account and you are being seen in the office, the balance will be required to be paid in FULL at the time of service.  NO EXCEPTIONS.  In the event of a separation/divorce, the parent bringing the child for an appointment is responsible for the co-pay or balance, which is due during that visit to our office. If one parent specifically is responsible for medical bills, we must be notified by both parties. Whichever parent/guardian signs this form, you will be held responsible for any amount owed and it will be your responsibility to collect from the other party.

Poole and Thomas Pediatrics does NOT accept Cost-share plans as these are not insurance policies. We will consider patients with this coverage to be self-pay and payment is due in full at the time of service. We will be happy to provide receipts for all services rendered that families can turn into their plan.

For all self/private-pay patients, you will be charged for care rendered at the time of service. Payment will be taken based on the information our front office staff has available to them at the time of the appointment (Good faith estimate). Once the provider completes documentation in the patient’s electronic health record, additional codes/fees may be incurred and billed to you during the next billing cycle. Should this occur, we are happy to provide an updated charge slip upon request. 

Please note, if your child is being seen for a Well Child Check and you have other concerns that are not related to routine wellness care, these may generate other charges to your insurance. A listing of potential charges can be found in our office and per request in the portal.

No-show or late cancellation fee: A fee of $35 will be charged to patients who do not provide 24-hour notification to cancel an appointment or for patients who miss their scheduled same-day appointment.

After 3 no-shows or late canceled appointments, your family may be discharged from the practice.

If a new patient misses their initial visit they may be dismissed from the practice. 

Phone triage: After hours, we offer a telephone triage consultation service that puts you in touch with a pediatric-trained triage nurse.  Families will be charged for each triage call made ($16). There are exceptions for advice given for infants less than 90 days old or where recommendations are given to immediately be seen by a healthcare provider. Additionally, if a provider speaks with a parent directly after hours or on the weekend, the call will be billed to your health insurance.

Weekends and After-Hours visits: There is an additional fee for appointments on late evenings, weekends, and holidays that may or may not be covered by your insurance. Any unpaid charges will be your responsibility.

Payment: We accept cash, debit cards, Visa, MasterCard, Discover, Amex. We will not accept checks as a form of payment.  Our staff or contracted billing company, PedsOne, may contact you at any of the numbers provided by you in an attempt to resolve any outstanding balances.  All questions regarding visit-based billing can be answered by PedsOne at 866-371-6118. 

We require that every family activates a portal account as this will be our way of appointment reminders, requests for forms, and many other features. Please email portal@ptpediatrics.com to set up.

You can expect to receive billing statements from our billing company (PedsOne), our vaccine supplier (Vaxcare), or directly from our office and payment is due within 30 days.  If you have not made a payment within 30 days from receipt of the statement, you will receive a letter asking for payment.  If we do not hear from you at that time, your account will be turned over to a professional collection agency.  This will result in the termination of the physician/patient relationship. 

Assignment of Benefits/Authorization: As the parent or legal guardian, I authorize payment of medical benefits directly to Poole and Thomas Pediatrics, PLC for services rendered. I further agree to be fully responsible for all lawful debts incurred for these services.

 

At Poole and Thomas Pediatrics, we are committed to protecting the security and privacy of your child’s personal information. Medical records are the property of Poole and Thomas Pediatrics. These records are kept in a secure location and are accessed only for the purposes outlined by the Notice of Privacy Practices (Revised 9/23/13). Our revised Privacy Notice is available at www.ptpediatrics.com, or you may request a copy from our office. Records may be released or shared with other healthcare professionals for the treatment of your child. Patients are entitled to one free copy of their medical records only after an authorization for release is signed. 
 
By signing below, I acknowledge that I have received Poole and Thomas Pediatrics Notice of Privacy Practices and consent to treat information. I understand that I can edit any of the terms below. I understand that PTP may call my home and place of employment for healthcare reasons, appointment reminders, to resolve billing issues, and may mail me information postcards to my home address. PTP may also mail bills to my mailing address.

I understand that PTP may leave messages on my answering machine regarding appointments and limited lab information.

I understand that PTP may use an email address or fax, provided by me to communicate appointment information, billing issues, immunization certificates, lab and test results, and other forms requested by the parent.

I authorize PTP to email or fax immunization certificates and/or school forms, or to mail to my home address provided.

I authorize PTP to discuss patient information with adults or other minors present during the visit regardless of whether I am present.

I understand that if I send a picture of myself or child(ren) PTP may display it within the office.