Pediatric Partners S.C. Financial Policy

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
• 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.
• Pay your co-pay at the time of service. As participating providers with your medical plan our office is required to collect your copayment 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, co-insurance, policy deductible, and any and all non-covered services and the outstanding balance after your insurance company has submitted payment to Pediatric Partners, S.C.
• Pay a 1% Rebilling Fee for any account balance over 60 days.
• 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.

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 in the day, to calls that lead to an emergency 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 to our website www.pediatricpartnerssc.com for answers to their questions when the office is closed.

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 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. 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.

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 charging you an administrative surcharge of $25.00 for processing your co-payment after your visit. Pediatric Partners has a contractual agreement with the health insurance carriers to collect all co-pays on the date the services are rendered. Pediatric Partners accepts Visa, MasterCard and Discover.

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. 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.

Pediatric Partners will not get involved in custodial, separation or financial disputes involving or relating to divorced parents for a minor child(ren) we provide services to. The parent who signs the financial policy and registration form of the minor child(ren) will be the responsible party for payments of services rendered.

Pediatric Partners accepts MasterCard, Visa, and Discover.

If a check is returned to Pediatric Partners for “Non-Sufficient Funds”, a $50.00 fee will be assessed & collected.

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 Billing Dept. to discuss payment options, the account will be turned over to collections. If your account is sent to our collection agency a collection charge of 35% of the amount due will be added to the balance of your account.

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.

1% Rebilling Fee will be added for account balances over 60 days

• 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 visits - $25 Sunday/Holiday Office Visit - $100
• No-Show Visit (scheduled and were not cancelled 24 hours in advance) - $35
• Phone Consultative Services will be billed to your insurance plan based on the duration of the call ranging from $25.00 - $50.00
• Walk-In Fee - $50
• $25.00 Administrative Surcharge for processing your co-payment after your visit.
• 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.
• $10.00 Fee will be charged for account histories to include payments and visit information by date of service.

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.

I have read the above financial policy for Pediatric Partners S.C. and I agree to the terms listed above.

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