Thank you for choosing Pediatric Partners as your health care provider for your children. We are committed to providing you and your child/children with the highest caliber of care. As part of your relationship with Pediatric Partners a clear understanding of our financial policies is important so you will know what actions Pediatric Partners 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 insurance card at the time of service.
• Inform us as soon as possible if your insurance carrier changes and provide us with a copy (front and back) of your new card.
• Pay your co-pay at the time of service. As participating providers with your medical plan our office is required to collect your co-payment on the date of service. If you are unable to pay your co-payment at the time of your appointment the office will charge a $25.00 Administrative Surcharge for processing your co-payment after your visit.
• Submit payment and assume responsibility for any and all charges your health insurance company does not pay for. This includes your co-pay, policy deductible, and any and all non-covered services and the outstanding balance after your insurance company has submitted payment to Pediatric Partners.
• Pay your account balance in full within 30 days of receiving Pediatric Partners statement of outstanding charges. If your payments are not received and your account is not kept current, your account will be sent to Pediatric Partners Third Party collection agency. Please note you will be responsible for all collection fees.Provided below is a more detailed description of your financial responsibilities.

Telephone Consultation Service

For busy families who may find it difficult to bring their children into the office, 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 a telephone consultation will be billed to your insurance company according to 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.

After Hours Telephone Calls

We will bill your insurance for non-urgent 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. This fee will not apply to calls related to follow up questions from office visits earlier that day, to calls that lead to an emergency room visit, or to calls that lead to an office visit to Pediatric Partners the following day. Daytime phone calls will continue to be free of charge, and parents are encouraged to look at our web site www.pediatricpartnerssc.com for answers to their questions when the office is closed.

If you have any questions regarding your responsibilities and/or our policies, please contact our Practice Manager.

Responsibility For Payment

Even though you have health insurance, you as guarantor are responsible for payment of all services provided by Pediatric Partners. Pediatric Partners 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.

Co-Payment

Your health insurance policy may state that you must pay a co-payment for physician visits. This payment is due the day services are rendered to your child/children. If, for an unforeseeable reason, you do not have the co-payment amount with you at the time of service, please be aware that Pediatric Partners will be telephoning you later in the day to obtain credit card information so this payment may be processed. Pediatric Partners accepts Visa, MasterCard and Discover. Pediatric Partners has a contractual agreement with the health insurance carriers to collect all co-pays on the date the services are rendered.

Remaining Balance After Your Insurance Company has Paid

Pediatric Partners will submit a claim to your primary health insurance company for services provided. Pediatric Partners does not submit claims to any secondary health insurance companies. You will be responsible for submitting claims to that carrier. Once your insurance company has processed your claim, Pediatric Partners 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.

Effective April 1, 2009, balances that are 60 days old will be assessed a finance charge of 1% per month.

Credit Card Authorization Forms

Pediatric Partners accepts MasterCard, Visa, and Discover. You have the option of completing a Credit Card Authorization form. By providing Pediatric Partners with specific credit card information, we will not have to telephone you when a co-payment was not received at the time of service. Credit Card information on file can also be used to pay your remaining balance after your insurance company has processed your claim. If after 30 days, Pediatric Partners has not received payment and you have completed a credit card authorization form, we will telephone and inform you that we will be using the credit card information on file to satisfy your outstanding account balance.

Check Returned for Insufficient Funds

If a check is returned to Pediatric Partners for "Non-Sufficient Funds", a $35.00 Fee will be assessed and collected.

Failure to Pay Outstanding Balance

If an account is not paid in full within the stated period of time of receiving Pediatric Partners Remaining Balance Invoice, Pediatric Partners will start the process of turning your account over to a third party collection agency for payment. You will be responsible for all associated collection fees imposed on Pediatric Partners by the third party agency.

Additional Fees

• Request for Medical Records — *
• Replacement of Standard Illinois Health (valid for most school and camp medical information requests): $10 *
• Medical release of information forms where the Standard Illinois Health Form cannot be used: $10 *
• Medical necessity Letters: $10 per letter
  
  
• Sunday / Holiday Office Visit: $100
  
  
• No-Show Visit (Visits that were scheduled in advanced and you did not cancel within 24 hours): $25
• Walk-in Fee: $50

* Please call for information from the medical records department.

Payment for these additional fees must accompany your request. In addition, if there is an outstanding balance on your account, Pediatric Partners will ask you to submit payment in full for the outstanding balance.