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 Limestone Pediatrics may impose.

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 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 who don’t have insurance coverage. 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.

We require that every family maintains a portal account. You will be able to see account balances, pre-check in for upcoming visits, request medication refills, and request forms (school physicals, Immunization records). To request a portal account please visit our website www.Limestonepeds.com to fill out our secure request form.

At Limestone Pediatrics, we feel strongly about children having routine check-ups. These visits allow us to monitor 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. Most insurance companies require annual visits (age 3-22yr) for preventive exams to be done 1 year and a day from the previous exam. The office will send out reminders when it is time to schedule for an upcoming physical. If physicals are not kept up to date after several attempts by our office to schedule, our Providers may dismiss the family from the practice.

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.

Edinburgh Postpartum Screening	Hearing and vision screening
Ages and Stages Questionnaire (development screening)	PHQ-9 Depression screen
MCHAT (Modified Checklist for Autism in Toddlers) at 18mo, 2yr	GAD-7 Anxiety screen
Spot Vision Screening 1yr – 5yr
Lead and TB exposure questionnaire

 

 

 

 

 

 

*Screenings

We follow the AAP (American Academy of Pediatrics) recommended screenings to be performed at certain visits. Insurance companies encourage us to administer these screenings at visits, even though some of them will pass the cost of the screenings to the patient rather than cover themselves. The office does not know the cost you may incur for these screenings as this varies between insurance plans.

Difference between Well Child Physical and Office Visits

Preventive visits and office visits may seem similar, but there is a difference. Knowing the difference can help ease any confusion.

You schedule well-child exams or “wellness exams” to help prevent or detect any health concerns. This is also known as your annual wellness exam or annual health maintenance exam.

Confusion comes when at your annual checkup you want to discuss or receive treatment for a new or existing condition that requires action by our provider. This is where a preventive visit can become an office visit, and your bill can be impacted.

Preventive Visit	Office Visit
Complete physical exam (annual health maintenance exam)	Diagnosing and monitoring specific medical conditions
A thorough review of medical history, general health and well-being	Addressing medical concerns and treatment plans
Developmental screenings* Evaluation of future risks	Medication refills
Vaccination review and update	Addressing new or worsening symptoms
	Specialist referrals Testing/lab results

Depending on your insurance benefits an office visit can result in additional costs.

 

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 to 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.

 

Please request a medication refill by portal 1 week prior to running out of 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 to have these prescriptions managed by our office. Medication refill requests must be submitted 1 week before running out.

When you are seen for a weekend visit or a visit that is also a Federal holiday per your insurance we must add the extended code. If your insurance company defers the responsibility of payment to you or your family, this is the decision of your insurance provider, not our practice. If you have concerns with what your insurance company covers, we recommend you call them directly to discuss your benefits and any coverage concerns.

Limestone Pediatrics does not get involved in disputes between divorced, separated or custodial parenting arrangements regarding financial responsibility for their child's medical expenses. By signing below, you agree the parent bringing the child for an appointment is responsible for the co-pay or balance, due at check-in, 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 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.

Providers at Limestone Pediatrics strive to stay on schedule. Although there can be urgent situations that prevent us from running on time, we pledge to provide quality care with minimal waiting time to the best of our ability. 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.

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 and we will advise whether you should come in or reschedule.
• Three (3) “no-show” appointments without notice from you in one year may result in dismissal from our practice.
• New patients who do not show without notice to their first appointment may not be scheduled for additional appointments.

If you are more than 10 minutes late for an appointment this appointment will need to be rescheduled for a later date or time and will incur a missed appointment fee of $35.

 

No-show/late 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. 

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

Limestone Pediatrics offers credit card on file. Card information is securely stored, and our office staff is only able to see the last 4 numbers of the card and the expiration date. This will help streamline the billing process. The card on file will be billed on the 15th of every month for any outstanding personal balance of $150 or less. If the account has a balance over $150 the billing department will contact you to have prior approval to process the payment. Once the card has been processed you will receive a receipt emailed to the email address we have on file.

This in no way will compromise your ability to dispute a charge or question the insurance company's determination of payment. You will be given time to contact our billing department and speak with one of our billing experts to discuss your charges.

Vaccinations are safe and effective in preventing diseases and health complications in children and adults. Limestone requires that all patients are immunized according to the current vaccine schedule recommended by the American Academy of Pediatrics and the CDC. 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.

Please allow 3-4 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 the requested FMLA paperwork.

Limestone pediatrics participates with the Kentucky Immunization Registry and Kentucky Clinical Document Exchange. Vaccines given to all patients in our office are entered into the KYIR (Kentucky Immunization Registry) system, a service of the Kentucky Department for Public Health that allows schools, individuals, parents and legal guardians to access official immunization records.

Kentucky Clinical Document Exchange allows different healthcare organizations to exchange patient records for treatment purposes. For example, if your child is seen by a specialist or in the Emergency Room, that provider can quickly access your child’s records to find out what medications your child is taking and/or if he/she has a medication allergy as well as demographics and diagnoses.

Only providers at healthcare organizations that participate in Clinical Document Exchange through the Interoperability Framework Care Quality can retrieve your records. They may retrieve your records for treatment purposes only.

If you would like to opt out of the sharing of information, please select the box below

The full copy of Limestone Pediatrics office policy can be found on our website Limestone Pediatrics or you may request a paper copy at any time.

Thank you for choosing and entrusting Limestone 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 care have risen significantly as well.

It is our goal to eliminate future misunderstandings regarding 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, and eligibility dates, along with 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/guardians. We must always have a current copy of your insurance card AND ID on file. 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 set 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 charges denied due to incorrect information.

Co-pays, Co-insurance and Deductibles will be expected to be paid at the time of service. Private Pay Patients are expected to pay in full at the time of service. If there is an outstanding balance on your account and you are seen in the office, the balance will be required to be paid in FULL at the time of service. NO EXCEPTIONS.

Limestone Pediatrics does not get involved in disputes between divorced, separated or custodial parenting arrangements regarding financial responsibility for their child's medical expenses. By signing below, you agree the parent bringing the child for an appointment is responsible for the co-pay or balance, due at check-in, 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 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. 

Important Terms

Deductible: This is the amount you are required to pay before the plan will pay any benefits for certain types of services

Copay: A fixed amount that the participant pays for an office visit. Copays do not apply to the deductible in the PPO Plan

Coinsurance: After the deductible is met the participant shares in the cost of medical care until the plan’s maximum is met

Out-of-pocket Maximum: The maximum amount the participant would be responsible for paying in the calendar year for covered expenses (includes medical copays, coinsurance, and deductible.)

Preventive Visits and Problem Focused Visits

Limestone Pediatrics requires a yearly physical at our office. At preventive visits we cover several very specific components including screenings, immunizations and counseling. Occasionally your child may also have a significant health issue raised during a well visit. We will need to bill for the work incurred for both accordingly (as problem-focused visits typically require a copay and/or a deductible may apply). Your insurance will process the visit codes according to your plan guidelines, applying copay, coinsurance, and/or deductibles as applicable. Health insurance contracts dictate your financial responsibilities, and you will receive a bill for these additional services.

Most insurance companies only cover 1 physical/well examination a year. If you are seen at an outside facility for a physical/sports physical your insurance may not cover your yearly physical at our office. It is your responsibility to know your insurance benefits. If the benefit has been used for the year you will be responsible for any balance that the insurance deems to be your responsibility.

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, Federal Holidays, After-Hours, and Visit Complexity codes: The Center for Medicare and Medicaid Services establishes guidelines for appropriate billing for the services we provide. Deviation from these guidelines can be considered fraud. We are required to bill the same for all patients regardless of whether your insurance company chooses to comply with these guidelines. If your insurance company defers responsibility of payment to your or your family, this is the decision of your insurance provider, not our practice. If you have concerns with what your insurance company covers, we recommend you call them directly to discuss your benefits and any concerns regarding coverage.

Payment: We accept cash, debit cards, Visa, MasterCard, Discover, and Amex.  Our staff or contracted billing company, PedsOne, may contact you at any of the numbers provided by you to resolve any outstanding balances.  All questions regarding visit-based billing can be answered by PedsOne at 866-371-6118.  If HSA is used as a form of payment and it is later determined it was an overpayment and you have received a refund, it is your responsibility to rectify this with the HSA company.

You can expect to receive billing statements from our billing company (PedsOne), or directly from our office and payment is due within 30 days. 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 Limestone Pediatrics, PLC for services rendered. I further agree to be fully responsible for all lawful debts incurred for these services.

Credit card on file: Limestone Pediatrics offers credit card on file to help streamline the billing process. Card information is securely stored, and our employees are only able to see the last 4 numbers of the card and expiration date. The card on file will be billed on the 15th of every month for any outstanding personal balance of $150 or less. If the account has a balance over $150 the billing department will contact you for prior approval to process the payment. Once the card has been processed you will receive a receipt to the email on file. If the card on file declines when the payment is processed the billing department will reach out to notify the family that updated payment information is needed. Failure to respond to the billing department or the office within 10 days will necessitate a fee of $25 be applied to the account for untimely payment.

Keeping a credit card on file will in no way compromise your ability to dispute a charge or question the insurance company's determination of payment. You will be given time to contact our billing department and speak with one of our billing representatives to discuss your charges.

Portal: We require that every family activates a portal account. You will be able to see account balances, pre-check in for upcoming visits, online scheduling, request medication refills, and request forms (school physicals, Immunization records). To request a portal account please visit our website www.limestonepeds.com to fill out our secure request form.

 

The full copy of Limestone Pediatrics office Financial Policy can be found on our website Limestone Pediatrics or you may request a paper copy at any time.