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 Limestone Pediatrics. In addition, I give permission for the following person(s) to bring my child to Limestone Pediatrics in my absence and to act on my behalf in authorizing medical care and treatment in my absence. In the event of an emergency or other illness, I understand that the providers and staff of Limestone Pediatrics will deliver any medical care deemed necessary regardless of the accompanying adult.

Anyone not mentioned above who brings your child into the office for treatment must have a signed authorization from the child(ren)'s legal guardian. Until we are notified in writing with legal documents, Limestone Pediatrics will assume that a child's biological and/or legal parents are both legal guardians who have access to medical treatment options and billing information for that child.

 

 

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. 
 

Registration will be updated every year at the first of the year or when a change has occurred with the address. 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 before the appointment, parents will be asked to complete a paper form upon check-in for their appointment, and will not be taken back for their visit until completed.

We require that every family maintain a portal account. You will be able to view account balances, pre-check in for upcoming visits, request medication refills, schedule well-child visits, and acute illness visits, as well as request forms (such as school physicals and Immunization records). To request a portal account, please visit our website at www.Limestonepeds.com to complete our secure request form. We will be utilizing some triage through the portal in the near future. We will send out updates and instructions once this is available.

Billing questions will be handled directly by Limestone Pediatrics Billing department. Please call the office with concerns.

Limestone Pediatrics offers a 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.   

All new 2026 patients at Limestone Pediatrics will be required to have a credit card on file, as well as any families who have received a 60-day notice of past due balance.

 

Limestone Pediatrics also highly encourages all established families to have a credit card on file to avoid past due balances.  
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. To protect our patients, we do not accept families who don’t vaccinate their children. Although recommended, 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.

When you are seen for a weekend visit or a visit that is also a federal holiday per your insurance, we will add an additional code to your child's visit in compliance with the Center of Medicaid and Medicare (CMS) billing laws. 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 about what your insurance company covers, we recommend you call them directly to discuss your benefits and any coverage concerns.

Our focus is the well-being of your child(ren). We are unable to mediate between any personal issues concerning the child’s parents or guardians.

 

Either parent or legal guardian can schedule an appointment for their child, be present for the visit, and/or sign for the release of the child’s medical records. Please make decisions regarding the treatment of your child (vaccinations, medications, circumcision etc.) prior to the appointment. Any restrictions on parental involvement in the child’s care must be clearly presented via a court-issued document. *See box below for more information. Unless legal documents are provided, we cannot limit the other parent’s involvement in the child’s care. As needed, both parents should consult with counsel to provide clear instructions to caregivers.

Request for a parent to be removed or denied access must be:

*Submitted in writing via the portal, mail, or in person.

*Accompanied by legal documentation with reference to the page that contains the    information that substantiates the request.

*Once received these documents are sent for legal advice.

• It is recommended that both parents have their own Patient Portal account, so that each has access to their child’s medical information. 

 

• Payment (co-pays, deductibles, etc.) is due at the time of service regardless of which parent is responsible for medical expenses. We are not a party to your divorce agreement. We will collect payment due from the parent who brings the child to the visit. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to request reimbursement from the other parent. 

 

• Either parent/legal guardian can sign for permission to treat and designate who they feel comfortable bringing the child to appointments etc. This means other people (grandparents, nannies, step or other parents etc.) are authorized to bring your child to our practice and can consent for treatment during that visit. If their names are on the forms by a parent/guardian.

 

• Stepparents married to a biological or legal parent are not considered legal guardians unless there is something in place from the other biological parent that gives up guardianship rights of the child, such as legal adoption.

Additionally, Limestone Pediatrics providers and staff cannot initiate a call to the non-attending parent before or after a child’s visit for:  
1.  consent prior to treatment,  
2.  to inform the other parent whenever visits are scheduled  
3. to communicate care information.  

• Tolerate appointment scheduling/cancelling patterns of behavior between parents. 
• Prevent another parent from making demographic account changes unless legally specified. 

PLEASE NOTE: 
SHOULD THE ISSUES THAT COME BETWEEN PARENTS BECOME DISRUPTIVE TO OUR PRACTICE OR IMPEDE THE CARE OF CHILDREN, WE RESERVE THE RIGHT TO DISMISS YOUR FAMILY FROM FURTHER TREATMENT FROM OUR PRACTICE. 
 

Limestone Pediatrics is committed to providing and maintaining the best possible care for our patients. Your review of billing practices in advance allows for good communication and common understanding. Medical offices that take insurance get paid by coding what they do. These codes are designated by the Center for Medicaid and Medicare Services (CMS) for all types of insurance.

 

G2211 is a new code from CMS created for primary care providers to indicate that they are following patients longitudinally and are committed to caring for the whole patient over time. The pediatricians at Limestone Pediatrics take pride in providing continuity of care. This code is added to all patient encounters except those designated as Well Child Checks. Please contact your insurance company if you have questions on how they process this code.

Insurance company billing policies dictate that we differentiate between two types of services.

*WELLNESS Services and PROBLEM ORIENTED Services 

What may be included in WELLNESS Services? (also known as a preventative visit or physical or well child check)

Age-appropriate history	Preventive counseling (such as proper nutrition)
Age-appropriate medical exam	Review of vaccine history
Review and interpretation of any recommended labs	Anticipatory guidance (such as reducing fall risks for early walkers)

What other WELLNESS/PREVENTATIVE related services will be billed separately? 
 

Vaccine products	Vaccine administration service
Routinely Recommended Labs	Screenings (Vision, Hearing or developmental screens

The Affordable Care Act allows for many wellness and/or preventative services to be covered in full by most insurance plans. However, this is not true of many problem-oriented services. Evaluation and/or management of any complaint and/or symptom offered by a patient or identified upon questioning during a wellness exam constitutes a problem-oriented service which may result in your insurance company processing your claim using both wellness benefits and problem-oriented benefits.

PROBLEM ORIENTED Services

Some common examples of problem–oriented services include but are not limited to:

Illness addressed (ears, eyes, nose, throat, cough, fever, etc.)	Chronic conditions addressed (obesity, asthma, ADHD/ADD, Anxiety/Depression etc.)
Management of Medication Refills	Behavior Concerns

We perform all screens recommended by the American Academy of Pediatrics, seeking to uncover any conditions that would lead to suboptimal health in years to come. Some Insurance plans consider screens as a problem-oriented service and may generate cost sharing in the form of copayment, co-insurance and, or deductible. Examples of screening services include but are not limited to:

Vision Test	Mental Health Questionnaires	Hemoglobin
Hearing Screening	Adolescent Questionnaire	Developmental Screening

Our medical practice wants to provide the most up to date, comprehensive care possible, which is why we address these issues during wellness visits. Additionally, we try to eliminate the need for the patient to return to the office, whenever possible. It is the responsibility of the policyholder to be aware of their insurance plan’s benefits and coverage. The deductible, copay, coinsurance or out-of-pocket expenses agreed upon between you and your insurance company are out of our control.

Well Check-ups are required  
At Limestone, 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, school forms, and therapy orders will not be completed for patients who are behind on well checks. Physicals for 3-22 years are done on a yearly basis and most insurance companies requires these to be done 1 year and a day from the last physical. 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.

 

 

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 associated; however, some recommend the screening but push cost to the patient’s deductible/co-insurance. Some do not cover the recommended screening at all even though they dictate they be done. It is a parent’s responsibility to understand which screening services are covered by your specific insurance plan.

 

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

Well visits may reveal problem-oriented issues that require evaluation and management (for example, ear infections, ADHD concerns and follow ups, Anxiety and Depression). Insurance company billing policies then prompt charges for both categories when there is an added diagnosis to the well appointment. While well checks/preventative services may not require a co-pay or deductible, problem-oriented services do. Some insurance companies have begun to push some Well Child Physicals and Vaccine cost responsibility to the patient. Please check with your insurance carrier to see what their Well Child Coverage is.

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 in office every 3-4 months once they are stable on their medication. Children with 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 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.

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.

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 wait time to the best of our ability. 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 weather you should re-schedule.
• 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.

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 cancelled 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 $20. 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.  

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

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, eligibility dates, along with what is and is not covered by your plan. If claims are not paid insurance 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 ensure that your address, phone numbers, and insurance information are always up to date for both parents/guardians.

Our office must have a current copy of your insurance card and photo ID on file. 
If your insurance changes, you must notify us immediately with the effective date of your new policy.

Failure to provide accurate or updated information may cause claim denials, which will become your financial responsibility. 

If incorrect insurance information is submitted and we do not receive updated information or communication after outreach attempts, a $50 reprocessing fee will be applied to your account. 

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 that 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.  

 

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

Copay: 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.) 

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.

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 cancelled appointments, your family may be discharged from the practice. If a new patient misses their initial visit they may be dismissed from the practice.

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 $20. 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.

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 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.

We accept cash, debit cards, Visa, MasterCard, Discover, Amex.   Our billing team may contact you at any of the numbers provided by you to resolve any outstanding balances.  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. If we receive a returned check there will be a fee of $50 added to the account. You can expect to receive billing statements from our billing department 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, and you will be responsible for all agency and legal fees incurred.

Limestone Pediatrics offers a 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 the 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.

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.

Payments that exceed your balance and result in an overpayment are reviewed monthly. We will attempt to contact you if this should occur. Accounts with personal credit balances will not be refunded unless all other charges have been processed by insurance.

Once verbal consent by the parent for vaccination is received, any charges for those vaccines if refused once drawn up and prepared for administration, will be the patient responsibility and are not billable to insurance.

Patients without or not using insurance will be provided a Good Faith Estimate (GFE). The GFE is only an estimate of items or services reasonably expected to be furnished at the time it was issued. Actual items, services, or charges may differ from the GFE once the provider completes the billing for the visit.

We require that every family maintain a portal account. You will be able to see account balances, pre-check in for upcoming visits, request medication refills, scheduled well child visits, and acute illness visits 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. We will be utilizing some triage through the portal in the near future. We will send out updates and instructions once this is available.