Paint Creek Pediatrics & Adolescent Care, P.C.
Financial Policy
(effective June 1, 2011)

Our goal is to provide and maintain a good physician-patient relationship.  We are committed to delivering prompt, accessible, high quality pediatric care to our patients.  You are responsible for providing us accurate and up to date personal information.  It is your responsibility to pay for our services as they are rendered.  PAINT CREEK PEDIATRICS & ADOLESCENT CARE, P.C. IS UNABLE TO PROVIDE FINANCING FOR SERVICES PROVIDED. This policy is designed to make our financial relationship clear to our patients.  Please read this carefully and if you have any questions, please do not hesitate to ask a member of our staff.

1. On arrival, please sign in at the front desk and present your current insurance card at every visit.  You will be asked to sign and date the file copy of the card.  This is your verification of the correct insurance and consent to bill them on your child’s behalf.  IF THE INSURANCE COMPANY THAT YOU DESIGNATE IS INCORRECT, YOU WILL BE RESPONSIBLE FOR PAYMENT OF THE VISIT AND TO SUBMIT THE CHARGES TO THE CORRECT PLAN.
2. If we are your primary care physician, make sure our name or phone number appears on your card.  If your insurance company has not been informed that we are your primary care physicians as of this date, you may be financially responsible for the visit.  Newborns must be added to your insurance policy as soon as possible.
3. According to your insurance plan, you are responsible for any and all co-payments, deductibles, and coinsurances.
4. Co-payments are due at the time of service.  You should be prepared to make payment for these when in the office.  Failure to pay a required co-payment will incur a $5 charge.
5. If our physicians do not participate in your insurance plan or you do not have health insurance, payment in full is due at he time of service.  If unable, 50% will be due at time of service with the remaining 50% due within one month.  Arrangements must be made with our billing service.
6. Patient balances (balances after insurance processing or charges not covered by insurance) are due immediately.
7. Any account that is 60 days past due will incur a $20 service charge.  Accounts that are 90 days past due will be sent to a collection agency and further elective medical care will be denied.
8. It is your responsibility to understand your benefit plan.  It is your responsibility to know if a written referral or authorization is required to see specialists, if preauthorization is required prior to a procedure, and what services are covered.
9. There is a 24 hour cancellation policy.  A $25 charge will be assessed for appointments not cancelled by the day prior to your child’s scheduled appointment.
10. A $30 fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.
11. There is a $25 charge per family to copy or transfer medical records.
12. Advance notice is needed for all non-emergent referrals.  Referrals generally will take between one and two weeks to complete.  It is your responsibility to know if a selected specialist participates in your plan.  Remember, your primary care physician must approve referrals before being issued.
13. Before making an annual physical appointment, check with your insurance company whether the visit will be covered as a healthy visit.  Not all plans cover annual healthy physicals or hearing and vision screenings.  It is your responsibility to know your insurance plan benefits.  If it is not covered, you will be responsible for payment at the time of visit.
14. Not all services provided by our office are covered by every plan.  Any service determined to not be covered by your plan will be your responsibility.