Financial Agreement and Guarantee:
I accept full and complete financial responsibility for all medical services rendered to the registered patient(s) and agree to all insurance co-payments, deductibles, and coinsurance that may be required under the terms of my medical insurance policies, as well as pay for any medical care that is considered a “non-covered” service under the terms of my medical insurance plan. This includes any fees incurred for medical record paper or memory device copies and after-hours phone calls.
• I further acknowledge, understand and agree, that in the event that I fail to make such payments in accordance with the payment policies of Complete Care For Kids, or in the event of default of my financial obligation to pay for services rendered, Complete Care For Kids may terminate the “doctor-patient” relationship with the family in accordance with the Code of Virginia. Furthermore, in the event of my default of my financial obligation, should my account be turned over to an external collection agency for non-payment, I agree to pay any associated collection costs.
• I understand that it is my responsibility to confirm that the physicians at Complete Care For Kids are part of my insurance plan network. If they are not and I obtain medical care, I will be responsible for the full cost of any and all visits.
• I agree to pay any and all fees associated with services rendered at the time of the visit unless I’ve made prior arrangements with Complete Care For Kids.
• I understand that I will be notified of any balance due via the Portal.
• I understand that any balance is due UPON RECEIPT of the billing statement sent via the Portal. A Late fee of $25 per month will be added if not paid.
• I understand that if the balance is not paid within 90 days nor payment arrangements made, CC4K will be forced to engage SUBMIT TO SMALL CLAIMS COURT.
• I understand that if I fail to my newborn to my insurance plan within their required time-frame, I will be financially responsible for any visits.
Copayments, Coinsurance, and Deductibles:
Depending on your insurance policy, a co-payment and/or deductible or coinsurance may be required at the time of service. Payment may be made in your Portal or on our website, as well as by check or by credit card. We also accept Health Savings Account (HSA) cards for payment. Please note that the co-payment is a contractual requirement from the insurance company and cannot be written off by the clinic. If you participate in a High Deductible Health Plan (HDHP) and have not yet paid your deductible in full, it is likely that any non-preventive services will require payment at the time those services are rendered. Coinsurance may apply even after meeting your deductible.
Why there may be a copayment due at the time of a Preventive Service Visit (Well Child Visit)
* The purpose of a Preventive visit is to review overall health, growth, and development and to identify risks and concerns that may get in the way of a child thriving. There are certain screenings we will do based on the recommendations of the American Academy of Pediatrics, discuss ways to promote development, answer questions regarding these subjects, and give any age-appropriate vaccines.
* The purpose of an Office visit is to discuss or get treated for a specific health concern or condition. You may have to pay for the visit as part of your deductible, copay and/or coinsurance, depending on your insurance plan.
• Unfortunately, at this time, MOST insurance companies are penalizing us for addressing any acute or chronic medical issues during a Well Visit/Check up/Physical. Therefore, if your child is found to be ill when they arrive for a Well Visit, we will address the illness and re-schedule the Well visit.
• If you have any major concerns about your child’s health, please do not wait until the Well Visit. Any concerns should be discussed as soon as they arise and SEPARATE from the Well Visit. In addition, if your child is on any chronic medications, for ADHD, Depression, Anxiety, or Asthma for example, we require that they have separate medication visits every 3 months, unless otherwise arranged with the physician. We will do our best to accommodate work and school schedules and utilize telemedicine when appropriate.
• If, during the Well Visit, the physician identifies any concerns or makes any diagnosis, an Office Visit fee will be billed IN ADDITION to the Well Visit. This will incur any applicable co-pays, deductible, or co-insurance fees based on your plan.
Authorization For Release Of Information:
I hereby authorize Complete Care For Kids to disclose all or any part or the contents of the medical record of the patients provided for and named in the Patient Registration to such insurance companies, organizations, or agencies that may be concerned with the payment of medical services rendered to the registered patient(s) consistent with the Health Insurance Portability and Accountability Act (HIPAA). This authorization is given with full knowledge and understanding that such disclosure may contain information which may result in a valid denial of insurance benefits, or which otherwise may not serve the interests of the registered patient(s) or myself.
Assignment of Benefits:
I hereby authorize release of information necessary to file a claim with my insurance company and assign payment of all medical benefits to Complete Care For Kids. In addition, I authorize the release of my child/dependent’s medical information by or between my treating physician and my insurer, HMO, health benefits payer, or any other entity (including but not limited to third party administrators, management companies, and provider networks) included in the administration of my child/dependent’s health benefits.
Patient/Parent/Guardian Responsibility:
I understand that whoever accompanies my child to their appointment has authorization to consent to medical care as needed, and is responsible for payment of medical services. I acknowledge my responsibility for payment of all services provided by Complete Care For Kids in accordance with the practice’s fees and terms. In the cases where a parenting plan exists, the parent that brings the child in for the appointment is considered the guarantor and is responsible for payment.
Late Fees:
Unless previous arrangements have been made, I understand that my account becomes delinquent if not paid within 30 days after the bill is sent via the Portal. The unpaid balance becomes subject to a monthly finance fee of $25. Any balance that is 90 days overdue will warrant the balance and any administrative fees being assigned to a Small Claims Court submission and dismissal from the practice.