N G R A M P E D I A T R I C S , P.
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
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.
Date of Birth
Parent/Guarantor Printed Name Parent / Guarantor Signature Date