Pediatric Partners a Division of PediaTrust, LLC

Pediatric Partners S.C. Financial Policy (download financial policy here)

Pediatric Partners/PediaTrust, LLC is committed to providing the highest quality health care for your child. As part of your relationship with PediaTrust, LLC a clear understanding of our financial policies is important so you will know what actions PediaTrust, LLC will be undertaking on your behalf as well as what your financial responsibilities are. Your health insurance policy is a contract between you and the insurance company. You have certain responsibilities to ensure that proper, accurate and timely submission of charges occurs.

You are required to:

• Present your primary insurance card at the time of service.
• Present a picture ID (driver’s license preferred) for verification of identity.
• Inform us as soon as possible if your insurance carrier changes and provide us with a copy (front and back) of your new card.

We will bill according to insurance guidelines for calls to the on-call physician when the office is closed. Each insurance company has their own policy related to reimbursement for these services, and it is your responsibility to understand your company’s policy, and any fees you may be directly responsible for. We will not bill for calls related to follow up questions from office visits from the previous seven days, for calls that lead to an emergency visit, or for calls that lead to an office visit to Pediatric Partners the following business day.

This service will be offered for families who have questions that require significant physician time, such as behavioral and developmental issues, follow up for chronic illnesses, or special services such as those related to travel health. Fees for telephone consultation will be billed to your insurance company according to the established guidelines. As with the after hours calls, each insurance company has their own policy related to reimbursement for these services, and it is your responsibility to understand your company’s policy, and any fees you may be directly responsible for. Of course, if you prefer, you may continue to bring your children into our office for this care.

Even though you have health insurance, you as the guarantor are responsible for payment of all services provided by Pediatric Partners, PediaTrust, LLC will bill your insurance company for all services rendered, with the information you have provided us. If your insurance information has changed, please notify us immediately so we may bill the correct insurance carrier.

Your health insurance policy may state that you must pay a co-payment for physician visits. This payment is due at the time services are rendered to your child. If, for an unforeseeable reason, you do not have the co-payment amount with you at the time of service, please be aware that PediaTrust, LLC will be charging you an administrative surcharge of $25.00 for processing your co-payment after your visit. To avoid this surcharge, contact the office within one business day of the visit to make payment. PediaTrust, LLC has a contractual agreement with the health insurance carriers to collect all co-pays on the date the services are rendered. PediaTrust, LLC accepts Visa, MasterCard, American Express, and Discover.

PediaTrust, LLC will submit a claim to your primary health insurance company for services provided. Once your primary insurance company has processed your claim, PediaTrust, LLC will post any payment it receives to your account. If there is a remaining balance, the balance is now your responsibility. This balance may include your deductible, coinsurance and any and all non-covered charges. Payment for this balance is due within 30 days of you receiving our statement of outstanding charges. Any balance due after 59 days will be subject to a 1% finance charge. This charge will be assessed monthly until the balance on the account has been satisfied.

PediaTrust, LLC will not get involved in custodial, separation or financial disputes involving or relating to divorced parents for a minor child. The parent who signs the financial policy and registration form of the minor child will be the responsible party for payments of services rendered; as stated co-payments are due at time of service.

Our office will make every effort to communicate with you about your account and will present reasonable options for payment. In the event a bill goes unpaid without contacting our PediaTrust Billing Dept. to discuss payment options, the account will be turned over to collections. If your account is sent to collection services a charge of 35% of the amount due will be added to the balance of your account.

• Request for Medical Records – See Medical Records Release Form.
• Checks returned to PediaTrust, LLC for "non-sufficient funds", a $50.00 fee will be assessed and collected.
• Replacement of Standard IL Health Form (valid for most school and camp medical information requests) - $10.
• Medical Release of Information Forms where the standard IL Health Form cannot be used - $10.
• Medical Necessity Letters - $10 per letter.
• After hours/Saturday visits - $15 Sunday/Holiday Office Visit - $15.
• No-Show Visit (scheduled and not cancelled 24 hours in advance) - $35.
• Phone Consultative Services will be billed to your insurance plan based on the duration and/or complexity of the call ranging from $25.00 - $50.00 .
• Walk-In Fee - $50 (outside of walk-in clinic hours).
• Administrative Surcharge for processing your co-payment after your visit - $25.00.
• A Collection Charge of 35% of the amount due will be added to the balance of your account if your account is sent to our collection agency.
• Request for account histories to include payments and visit information by date of service - $10.00.
• Payment for these additional fees must accompany your request. In addition, if there is an outstanding balance on your account, PediaTrust, LLC will ask you to submit payment in full for the outstanding balance.

I certify that my child is covered by the insurance provided and assign directly to PediaTrust all Insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

I have read the above financial policy for PediaTrust, LLC and I agree to the terms listed above.

Print Name ________________________________________  Date________________________________________

Signature _________________________________________

Pediatric Partners Financial Policies Apr 2009 modified Oct 2010, 
Nov 2010, Dec 2010, Jul 2011, Oct 2012 and Jan 2013