To all Parents/Patients:

The intent of this document is to inform you of Central/Priority Pediatrics, PA Financial Policy. Your understanding of our financial policy as it relates to your obligations is essential for a successful working relationship. Please read this document thoroughly. Please let us know if you have any questions.

Insurance:

· If Central/Priority Pediatrics participates with your insurance we will file your claims. If we do not have an active contract in place with your insurance, we will bill your insurance for you as a courtesy.

· All patients must present a valid insurance card at the time of service.

· New patients must present a valid insurance card at the time of their first visit. If no card is available their account will be set up as self-pay until such time as we receive a copy of their card.

· Priority Pediatrics is an Urgent Care clinic. It is the patient’s responsibility to obtain a referral from their primary care clinic.

Copays:

· You are expected to pay your copay at the time of service. All other balances not covered by your plan will be billed to you after receiving the explanation of benefits from your insurance carrier. If you have any questions or concerns on any non-covered balance by your insurance company, we encourage you to contact them for further explanation.

· Priority Pediatrics is considered an Urgent Care facility. Therefore, depending on your insurance, you may be charged an Urgent Care Copay when you receive services.

Patient Balances:

· You are responsible for your deductible/coinsurance and any other charges not covered by your insurance policy such as routine care, preventive services, immunizations, etc.

· Self-pay and no insurance patients will be asked to pay a down payment of $50.

· For patients with no insurance Central/Priority Pediatrics, PA does offer a 10% discount for paying services in full at the time of the appointment with cash or a check. Credit/debit cards do not qualify for a discount.

· All patient balances are payable in full within 30 days of your first statement. We are happy to accept payment arrangements.

· For your convenience we accept Cash, Personal Checks, Money Orders, Visa/MasterCard, American Express, and Discover as payment for services rendered.

· A $25.00 Returned Check Fee will be assessed to the account for every check returned to Central/Priority Pediatrics, PA for insufficient funds or closed accounts.

· It is our policy that any patient at the age of eighteen or older will be financially responsible for all charges incurred by them. This means that the account will be placed in that person’s name.

· Central/Priority Pediatrics, PA DOES NOT get involved with divorce or separation. For any patient under the age of 18, the parent who accompanies the minor for their visit will be financially responsible for all charges incurred. Including copays.

· We reserve the right to turn any account over to collections, if it is deemed that the account has been in default of the payment obligations specified in this policy.

I, ___________________________ have read and understand the above Financial Policy of Central/Priority Pediatrics, PA. I agree to the terms outlined in this policy and understand that if I do not comply with this policy, my account may be turned over to a collection agency for payment of debt.

SIGNATURE: ________________________________________ DATE: _______________________

(Signature of parent accompanying child)

Effective 04 01 05