Commercial health insurance.
As a courtesy, the physicians at Preferred Pediatrics LLC will file claims for healthcare services provided on my behalf directly to my health insurance carrier as long as my account remains in good standing. I hereby assign directly to the physicians any and all health insurance benefits to which I am entitled and which are payable to me for any services rendered.
No insurance or limited coverage.
If I have no insurance or limited coverage for the charges incurred on this account, I agree to pay the full balance of such charges at the time of service or in accordance with payment terms agreed upon by Preferred Pediatrics LLC. I am responsible for determining whether the services of Preferred Pediatrics LLC are covered by my insurance contract, for verifying that my correct insurance and contact information is on file, and for promptly notifying Preferred Pediatrics of any changes. Well visits, immunizations and any other charges denied by my insurance carrier are my financial responsibility.
Release of information.
I authorize Preferred Pediatrics LLC to release any and all medical information which may be requested by my insurance company to process insurance claims and remit payment, or which may be necessary in coordinating medical care with specialists or other healthcare professionals in the course of treatment. I authorize the use of my signature below on all insurance submissions made by Preferred Pediatrics LLC for healthcare services provided.
Scheduling.
I understand that well-visit appointments must be made in advance. I will arrive 5 to 10 minutes earlier than my appointment time and call if I anticipate being late. I will call 24 hours in advance if I need to cancel well visits or rechecks and will give at least two hours notice if I must cancel a sick visit.
NSF charge.
I agree to pay a $25.00 charge on all checks returned for non-sufficient funds.
