Billing Policies

All co-payments are expected at time of service. For your convenience, accepts cash, personal checks, and Visa/MasterCard / American Express/Discover debit and credit cards. Surcharges will be assessed for returned checks or co-payments not made at time of service.

You may elect to complete a credit card authorization form which will allow for your credit card to be charged at every visit. This can be used to pay for your co-payments, forms or non-covered services.

Our contracts with insurance companies require that we verify your current coverage and collect your co-payment at each visit. Please bring your insurance card to every appointment.

Fees for Non-Covered Services

The following fees will be charged for services that are not covered by insurance:
These charges and policies are described in full detail below.

Patient Financial Responsibility Statement

At the time of your first visit, you will be asked to read the following Financial Policy and sign that you acknowledge and accept our policy. This policy may be revised from time to time. We will always post the most recent version of the policy on this page of our web site.

Insurance Coverage

You must provide your insurance card or proof of insurance at the time of each visit. If you do not have insurance, are unable to provide proof of insurance, or are on a plan in which we do not participate, full payment is required at the time of your visit.

It is very important that you become familiar with your insurance plans and understand its benefits. Certain plans have restrictions on certain services such as vision/hearing screening, immunizations and timing of well child exams. It is your responsibility to be aware and understand your plans restrictions and limitations. Individual employers can modify plans. We often do not have information available about your specific plans If you have any questions regarding your coverage, health benefits, health restrictions and payment determination then you need to contact your insurance company directly.

Payment Methods

All co-payments and deductibles are due at the time of service. These fees by law cannot be waived. For your convenience, we accept cash, checks, ATM cards, Visa and MasterCard, American Express and Discover Cards.

Insurance

Children’s Wellness Center will bill insurance companies for which we are providers. You will be responsible for all co-pays and co-insurance at the time of services. Some of the services provided may be non-covered services and not paid by your insurance company. You are personally responsible for these services. You will receive a bill, which must be paid upon receipt.

If we are not a provider on your current plan or do not have proof of insurance than you will be responsible for the entire bill at the time of service. We will provide you with an encounter form at each visit so that you can file the claim with your insurance company.

Newborn Policy

Unpaid Balance

Unpaid fees in excess of 90 days will be subject to referral to a collection agency. This may affect your credit rating.

Medical Records

Medical records are the property of Children’s Wellness Center. You can request copies of medical records in writing. We will provide copies of required medical records to specialists free of charge. We will provide you with your copies within 30 days of receiving your written request.

Referrals

If your insurance plan requires a referral prior to seeing a specialist or using a hospital service then we will need greater than 24 hours notice. We cannot issue a referral once services have been rendered. It is your responsibility to know your insurance company requirements. We do not have access to that information many times.

Missed Appointments/Cancelled Appointments

Please give us at least 24 hours notice when canceling an appointment. Missed appointments seriously disrupt our practice. If you fail to show for two (2) consecutive well child appointments then you may be subject to a charge of $50.00.

A parent or legal guardian must accompany all children/teens under the age of 18. The parent or guardian can designate another person to seek medical care for their minor by filling out a required form.

Delinquent Accounts

A payment can be arranged with our business office for past due amounts. Failure to pay or arrange payment of a past due amount within 90 days will result in a referral to a collection agency. If this occurs then you will be responsible for all reasonable attorney fees, court costs and collection fees related to the delinquent account. Credit reporting is done by our collection agency and this may affect your credit rating.

I have read and understand the Financial Policy of WestCare Pediatrics and agree to the terms and responsibilities as described above. I also authorize Children's Wellness Center to release required medical or other information necessary to process my insurance claims. I also authorize payment of medical benefits directly to Children's Wellness Center .

Child’s Name _____________________________________________

Parent/Guardian Signature___________________________________

Date_______________

Relationship to Child_______________________________________