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Village Pediatrics (VP) Financial, Privacy, Vaccine, and Treatment Policies & Procedures Consent Agreement

Please initial each section acknowledgment and sign at the bottom of the form
Working with my Insurance

I authorize VP to submit each visit and service to my insurance company on my behalf. I authorize the release of any medical or other information for the purpose of providing care or securing payment for services rendered. I authorize the payment of medical benefits directly to VP.

I agree that I am financially responsible for any charges not covered by my insurance carrier for services provided by VP including but not limited to: co-insurance, copayment and/or deductibles and agree that I am to pay any of these non- covered charges at the time of service.

I understand and agree that if my insurance company subsequently notifies VP a rendered service is not a covered benefit for any reason on my insurance plan, I am to pay in full the amount not covered upon receipt of the patient statement (“EOB”) and my credit card will be charged.

Before making an annual physical appointment, it is my responsibility to check with my insurance company regarding whether the visit will be covered as a healthy visit.  Some plans allow one physical per calendar year, or once per 365 days.  If it is not covered, you will be responsible for payment at time of service.

Our practice firmly believes that providing medical care to children based on the type of insurance you have is contrary to our high-quality standards.  Thus, to provide the best pediatric care available to you consistently we follow the American Academy of Pediatrics recommended Bright Futures Guidelines.  Your insurance will make the decision about what will be paid for, you will be responsible for what is not covered.

During well visits if any ADDITIONAL concerns or conditions arise, these will have additional codes and charges and therefore may require a CO-PAY at your child's well visit as required by your insurance company.

It is your responsibility to know if a written referral or authorization is required to see specialists or preauthorization is required prior to a procedure or study.

Credit Card Policy

I understand that VP requires a credit card on file. My insurance requires payment at time of service for all deductibles, co-pays, and coinsurance. As a courtesy, VP will keep my credit card on file and process payment when the EOB is received from my insurance (you also receive an identical EOB detailing charges and patient responsibilities from insurance.) We are ONLY allowed to charge you what your insurance company says is your responsibility according to your health plan benefits.

If your stored card is declined, a bill will be sent with payment expected as well as an updated credit card within 7 days of receipt.  Bills can be paid by calling our office, or accessing our payment portal on our website or in the patient portal. Overdue bills will be assessed a $25 late fee.

I understand it is my responsibility to update my credit card on file when it expires or is replaced. Ccredit cards are stored electronically and are encrypted to protect private information. State and federally funded insured are not required to leave a credit card on file as there is no balance billing.

I understand that if I am a non-VP patient/visitor I am required to place my credit card on file. As above, state and federally funded insured are not required to leave a credit card on file as there is no balance billing.

Office Hours

Business hours at VP are M-F 8:30 am-5 pm. Services rendered outside of these times are considered after hours and CPT codes 99050 and 99051 apply. If my insurance does not cover these, I am responsible.

Administrative Fee

Payment of our “Added Benefits” administrative fee is a mandatory requirement of all patients of Village Pediatrics. This fee is waived for state or federally funded insured and visiting patient families. Please review the separate Added Benefits policy for full details. For calendar year 2019 I will incur an annual charge of $250 for children through age 4, $200 for children age 5 to 17, and $150 for young adults 18 years and older, with a family cap of $700.  This fee will be charged annually to my credit card, processed on January 1st if not paid prior to that date. This is the responsibility of the parent/guardian and cannot be submitted to any insurance carrier.

No Shows/Late Cancellations/Late Arrivals

I understand and agree that fees will be assessed for appointments cancelled or missed are $50 (missed or 4 hr cancellation) for sick visits, $100 (24 hr cancellation) for physicals or behavioral visits. Per state requirements, this fee is waived for state or federally funded insured.

We do our best to run on time and also need to honor the time of those who are prompt for their appointments; if you are more than 15 minutes late for a scheduled well child appointment we may need to reschedule the visit, and you may be subject to a missed appointment fee of $100.

Billing Details
Co-payments are due at time of service.  A $25 processing fee will be charged in addition to your co-payment if not paid at the time of service.

Village Pediatrics is not a party in divorce or separation agreements.  We bill one guarantor and expect at least one valid credit card will be kept on file for outstanding balances.  We do not handle billing or insurance coverage disputes between parents.  The individual bringing in the child for services will be held financially responsible for any co-payment or unpaid charges on the account at time of visit.

We do not submit to secondary insurance plans.  If you have secondary insurance, we will provide you with a receipt to submit for reimbursement.  Your secondary insurance will send the check directly to you.

A $50 fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.

I understand that if my account is over 60 days past due, the process of being sent to collection will be initiated. Should the account be referred to a collection agency, I will pay all reasonable fees and collection expenses, and I understand that all delinquent accounts bear interest at the legal rate. I will be able to receive emergency care for my children for 30 days but will not be able to schedule appointments until my account is settled.

Medical Records

I understand that my administrative fee allows me to receive a copy of my medical records on disc. Paper copies will be charged at the state rate of $0.65 per page. Records for non-emergent needs can take up to 30 days. As per State rules, state and federally funded insured are not charged for medical records.

Privacy Practices

I understand that the patient’s health information is private and confidential. I understand that VP works very hard to protect the patient’s privacy and preserve the confidentiality of the patient’s personal health information.

I understand that VP may use and disclose the patient’s personal health information to help provide health care to the patient, to handle billing and payment, and to take care of other health care operations.

VP has a detailed document called the “Notice of Privacy Practices”. It contains more information about the policies and practices protecting the patient’s privacy. I understand that I have the right to read the “Notice” before signing this Acknowledgement.

Within this Notice of Privacy Practices is contained a complete description of my privacy/confidentiality rights. These rights include, but aren’t limited to, access to my medical records; restrictions on certain uses; receiving an accounting of disclosures as required by law; and requesting communication be by specified methods or to an alternative location. This Notice of Privacy Practices may be updated periodically.

Acknowledgement of Vaccine Administration Policy

I understand that VP will administer vaccines in accordance to the American Academy of Pediatrics Guidelines. I also understand that I will be given information about these vaccines and the opportunity to discuss them prior to administration. VP does not accept families who do not vaccinate or under vaccinate their children or follow alternative schedules.

Permission to Treat

I understand that by signing below I authorize VP to provide medical care reasonable by today’s standards.

Acknowledgement of Financial Consent, Privacy and Vaccine Policy, and Permission to Treat

NAME of Parent/Guardian: