Thank you for choosing Sweetwater Pediatrics as your health care provider. Please understand that payment of your bill is considered a part of your care. The following is a statement of our Financial Policy, which we require you to read and sign prior to treatment.
Due to frequent changes in health insurance coverage, we require that you provide proof of insurance coverage at each visit. If you do not have insurance, are unable to provide proof of insurance coverage, or are on a plan in which we do not participate, FULL PAYMENT IS REQUIRED AT THE TIME OF YOUR VISIT.
All co-payments, co-insurances, and deductibles are due at the time of service. These fees cannot be waived. For your convenience, we accept cash, check, and Visa/MasterCard/American Express/Discover (including debit cards).
For those plans with which we do not have a relationship, you will be responsible for your entire bill at the time of service. We will provide you with a copy of your bill, at each visit, so you will be able to file a claim with your insurance company.
If we are a participating provider, all co-pays, co-insurance, and deductable amounts are due at the time of service.
Please be aware that some of the services provided may be non-covered services and not considered reimbursable under your insurance plan. You are personally responsible for these services.
We will routinely file your insurance claim for each visit. Should there be a dispute with your insurance company we will attempt to resolve it with you. During this time a statement will be mailed to you each month when your account shows a balance due. For all insurance other than HMO’s, if your insurance has not paid within 90 days; the balance may be transferred to your personal balance, which must be paid upon receipt. Your insurance policy is a contract between you and your insurance company; therefore, your balance is your responsibility.
VACCINES FOR CHILDREN (VFC) PROGRAM
Children who are not insured, or are insured but do not have vaccine coverage, are enrolled in Medicaid, or are American Indian or Native Alaskan qualify for the Vaccines For Children program. The vaccines are provided free of charge, but there is an administration fee, which is your responsibility. If your child qualifies and you would like to participate in the VFC program, it is required that the nurse be told at the beginning of your child’s visit. We cannot implement this program retroactively.
We Reserve the right to charge interest in the amount of 1.5% monthly (18% annually) As provided by the state law on all past due account balances.
The first request for participation forms for camp, school, sports, and ect. Will be free of charge. Any 2nd request for state forms will be charged a $10.00 fee payable in advance.
PATIENTS WHO ARE NOT ACCOMPANIED BY A PARENT OR GUARDIAN
All patients under the age of 18 years old must be accompanied by a parent or guardian. Should your child require treatment and a parent or guardian are unable to be present, a signed consent must be sent to you office prior to the visit. We will not accept phone consent.
RETURN CHECK FEES
A $25.00 processing fee will be charged for checks returned as insufficient funds, stop payment on an issued check and checks drawn on a closed account. This charge is applied to your personal account balance and must be paid within 14 days of notification to avoid further action. Any family account that has a history of more than two returned checks for insufficient funds will require cash or approved credit card payments for all visits thereafter.
If a large balance is outstanding and financial arrangements need to be made, a payment program may be arranged with our Practice Administrator prior to your visit. Failure to resolve any past due accounts including any returned checks will result in referral to a collection agency. In the event your account is sent to a collection agency, a 30% collection feel will be added to your outstanding balance.
We may need to disclose to a collection agency personal health information related to receiving payment for services rendered in the event your account is delinquent.
Any family whose account is forwarded to a collection agency will be dismissed from our practice. At this point, if you have a PCP assigned to you then you must contact your insurance company and request to be assigned to another office
TRANSFERING OF MEDICAL RECORDS
Because there are frequent changes in health insurance coverage and participating providers, it is often necessary for patient to ask that their medical records be transferred to another physician’s office. An immunization record, growth chart and overall summary can be provided at no charge. Otherwise, there will be a $25.00 administration fee charged for the copying of medical records.
Due to the increase number in refill request, we ask that you allow 48 hours from the time of your request for your prescription to be picked up or faxed to the appropriate pharmacy. We ask that you notify the office in ample time before running out of a necessary medication. Please note: routine prescriptions will not be called in after hours.
If you have been referred to a specialist/imaging center your insurance company may require you to have a referral. It is your responsibility to know the requirements of your particular policy. Should you need a referral, we ask that you notify our referral coordinator as soon as your appointment has been made. Please allow 48 hours for referrals to be faxed.
Any procedures performed by the lab nurse (lab work, hearing and vision, ect.) that do not require face-to-face visit with the physician will incur a nurse fee in addition to the procedure performed. All appropriate co-payments will apply.
A photo of your child will be taken at their first visit to encourage familiarity between our patients and staff. This picture is automatically attached to their chart and cannot be extricated for any other purpose. Should you object please let our receptionist know.
All patients are asked to please check out before leaving the office. It is unlawful to intentionally walk out without satisfying you financial obligations after treatment has been rendered.
Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.