Parents are responsible for any balance not covered by their insurance company. If a patient is uninsured, payment is due at the time of service. If an insurance claim is denied, payment is due within 30 days of the denial. Should you need to make payment arrangements, you must do so with our Billing Department within 30 days of the denial. If you are not sure of your covered benefits i.e.,Well Child Visits, it is your responsibility to contact your insurance or employer benefit office. If you have a deductible, the contracted amount will be collected in full at the time of service.

As a courtesy to you, we will bill your primary insurance company provided we are given current and complete information at the time of service. Many insurance carriers require a co-payment at the time of service. We are contractually required to collect the co-payment. We make no exceptions to this policy.

If your check is returned to us for insufficient funds, a $20.00 fee is applied to your account.

I have read and received a copy of the Credit Policy of The Pediatric Clinic. I accept this policy for treatment of my child with The Pediatric Clinic.

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Parent's First Name                                                                            Parent's  Last Name

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