New Patient Packet (Page 3 of 4) in pdf

New Patient Packet Page 3

Financial Policy Sheet

We are happy that you have chosen our practice to provide for your child’s health care needs.

We are committed to providing the best medical care and customer service available. As part

of this commitment, it is important that you have a clear understanding of our financial

policies. Our staff will be happy to answer any questions you may have.

Our physicians participate with most major insurance plans. Due to constant coverage

changes, we cannot guarantee that your insurance company will cover the service we provide.

We will file your charges as a courtesy. Should the services not be covered, you will be

responsible for the bill. It is your responsibility to pay your copay at the time of each visit.

We cannot bill you for your co-pay. It is also your responsibility to make certain that the

physician that your child is scheduled to see is on your insurance plan.

Unless arrangements have been made in advance either by you, or by having insurance

coverage, payment for all services is due at the time of service. For your convenience we

accept all major credit cards, cash and check.

I have read, understand and agree to abide by the financial policy of the practice. I hereby

authorize the release of information necessary to process insurance and also authorize my

insurance company to pay directly to the physician any benefits due for services rendered.

Patient Name _______________________________________________________________

Date of Birth ________________________________________________________________

Parent/Guardian Name (print) _________________________________________________

Parent/Guardian Name (signature) _____________________________________________

Date _______________________________________________________________________

New Patient Packet Page 3