Financial / Chaperone Policy

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I N G R A M   P E D I A T R I C S ,  P. A.




     Thank you for choosing our office to provide care for your child (ren). In order to prevent any misunderstandings and to serve you better, we ask that all parents read and sign our Financial Policy. If you have any questions, please ask a receptionist or a representative from our business office.


      As a courtesy, we will verify your insurance eligibility and benefits at your initial visit and any time you notify us of a change in your coverage. However, we cannot guarantee that the information we receive is accurate (at the time of verification or for later visits) or that the insurance company will process the insurance claim in accordance with the information they provided. You, as the holder of the insurance policy, are ultimately responsible for knowing what your plan does and does not cover (like check ups and immunizations and certain procedures).You are also responsible for verifying that your doctor is participating in your insurance plan. Any amounts not covered by your plan, except for contractual fee discounts, are your financial responsibility. Please read and initial each item below:


___1. COPAYS AND/OR COINSURANCE AMOUNTS ARE DUE AT EVERY VISIT.  Our office accepts MasterCard, Visa, Checks and Cash at the time of each visit.  If I have a deductible to meet, I will pay your normal charges on the date of service.


___2. NEW INSURANCE / CHANGE OF INFORMATION must be provided at the first visit after the change. I agree to provide this information before my child(ren) are seen. Failure to provide correct insurance information may result in the entire bill becoming my  responsibility.


___3. BALANCES OVER 90 DAYS OLD: I understand that if I allow my account balance to extend over 90 days, I may receive a Final Notice letter. Failure to pay my account or arrange a payment plan within 10 days may result in my account being turned over to a collection agency with an additional $ 30 charge. I will also have to find another physician within 30 days.


___4. CHANGES IN ADDRESS or telephone numbers should be provided immediately. Again, accounts over 90 days past due will be turned over to collection agency and a new physician will need to be obtained within 30 days.


___5. RETURNED CHECKS will incur a $30 fee.  If a second check is

returned on my account, I understand that my checks will no longer be accepted for payment.


___6. FEES SPECIFIED IN THIS POLICY are subject to change without prior notice and will be applied to your account at the current rate.


     If you have any questions regarding our financial policies, please don’t

hesitate to ask. Please sign below to acknowledge understanding of the entire policy and that a copy has been  provided  for your records.



Patient Name                          Date of Birth

_________________________      _______________________________

Parent/Guarantor Printed Name            Parent / Guarantor Signature         Date

Chaperone Policy
We at INGRAM PEDIATRICS, PA  are committed to providing a safe, comfortable environment where patients and staff can be confident that best practice is being followed at all times and the safety of everyone is of paramount importance. All patients are entitled to have a chaperone present for any consultation, examination or procedure where they feel one is required. This chaperone may be a family member or friend. On occasions you may prefer a formal chaperone to be present, i.e. a trained member of staffWhere this is not possible we will endeavour to provide a formal chaperone at the time of request. However occasionally it may be necessary to reschedule your appointment



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