Patient Financial Office Policies Agreement

 

Thank you for choosing Desert Ridge Children’s Center for your child’s healthcare needs.  We strive to provide quality medical care for your child and to develop long lasting relationships with our families. In order to reduce potential misunderstandings, we have established the following financial office policies. We require that you please read our financial policies as listed below and let us know if you have any questions regarding them..

· Your insurance policy is a contract between you and your insurance plan.  We cannot efficiently bill your insurance company unless you provide us with current and valid insurance information.  We will file claims to those plans with which we have a contractual agreement. Please understand that we submit billing claims to your insurance company as a courtesy to you.  You are ultimately responsible for all charges whether or not the claim is paid by the insurance company.  You will be held responsible for any balance on your account. For all services rendered to minor patients, the parent and /or guardian responsible for patient will be held responsible for payment.

· Our insurance contracts require us to collect deductible amounts and co-pays at the time of service. All co-pays and/or moneys due will be collected prior to services being rendered.

· For your convenience we accept VISA and MasterCard in addition to personal checks and cash. If your check is returned to us for any reason, we will add a service charge of $35 plus any charges accrued to Desert Ridge Children’s Center, by the bank. Future co-pays and/or dues will have to be paid in cash, credit card or money order ONLY.  Checks will no longer be accepted.

· Our goal is to provide the best possible care and physician availability to each of our patients. Our policy is to request you to call and cancel appointments 24 hours prior to the scheduled time. A $40 non-cancellation fee will be charged for no-show appointments and will be expected to be paid at the next visit.

· Copies of medical records are always available to you.  Under the HIPAA laws, you have the right to view your medical record documentation.  If you wish to have a copy of all your records, we will provide them for a $25 fee per patient.  A medical release form must be signed for each patient and we ask for a 72 hour preparation time. This can be paid when you pick up your records.  Copies will not be given to anyone other than the parent or legal guardian.

I have read the above financial policy. I understand its implications as they apply to me. I also agree to communicate to Desert Ridge Children’s Center of any changes in my billing information as required to fulfill the medical and financial obligation for services rendered.

 

Insurance Information:

 

Name of Insured:_____________________________        Relationship to Patient:________________________

Insurance Company:_______________________ ID #_____________________ Group #_________________

 

I hereby authorize payment directly to Desert Ridge Children’s Center for medical and/or surgical services rendered to me, if any from my insurance carrier. If paying cash, I am responsible to pay at the time of service

 

_______________________________________                            ________________________

Parent or Legal Guardian                                                                        Date

 

_______________________________________                            ________________________

Witness                                                                                                         Date