This payment policy has been developed by Town and Country Pediatrics to inform our patients regarding patient and insurance responsibilities for services rendered. This signed policy will be placed in your child's medical record. If you would like to expedite your next visit please read, print, sign and bring it in to the office.

1. Insurance.

We participate with most PPO insurances, except CIGNA and UNICARE. You can find the list of insurances we participate at our offices or on our website. If you are insured by a plan we do not have a contract with, payment in full is expected at each visit. If you do not present an up-to- date insurance card or if we cannot verify your coverage, payment in full is required at each visit. Knowing your insurance benefits is your responsibility. Please contact your insurance company regarding your coverage and benefits.

2. Co-payments and deductibles.

All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance and we have to comply with its terms. Please help us keep within our contract terms by paying co-pays at each visit.

3. Non-covered services.

Please be aware that some or perhaps all of the services you receive may not be covered or not considered reasonable or necessary by your insurance. In such cases, you will be responsible from the balance of any outstanding charges.

4. Claims submission.

We will submit your insurance claims and help you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to it.

5. Proof of insurance.

All patients must complete our patient information form before seeing the health care provider and update it regularly. We must obtain a copy of your current valid insurance card to provide proof of insurance. If you fail to provide us with correct insurance information in a timely manner, you may be responsible for the balance of your claim.

6. Coverage changes.

If your insurance changes, please notify us before your next visit and provide us with your new insurance card so that we can make the appropriate changes to help you get maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

7. Nonpayment.

If your account is over 60 days past due, you will receive a letter stating that you have 20 days to pay your account. Partial payment will not be accepted unless you call and make a payment arrangement with the billing department. Please be aware that if the balance remains unpaid, we may refer your account to a collection agency and your family members may be discharged from this practice. If this occurs, you will be notified by certified mail, your records will be sent and you will have 30 days to find alternative medical care.

8. Missed appointments.

Our policy is to charge $50 for 15 minute and $100 for 30 minute missed or cancelled appointments without giving a 24 hour notice. These charges will be your responsibility and billed directly to you.

9. Other fees and charges.

After hours appointments have an additional $25 charge. After hours phone calls that are paged to a physician on call by the answering service are charged $25. School/camp forms after the first request are charged a $5 fee per form. Any walk-in patient for an emergency visit will be charged a $50 fee.

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Signature of parent or responsible party

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