Pediatric Associates of Western CT Financial Policies
Pediatric Associates of Western CT strives to provide the best medical care for your children. As a courtesy, we will file your insurance claim on your behalf. It is your responsibility to provide us at the time of service, complete and accurate insurance information and to respond to all coordination of benefits requests by your insurance company. Failure to do so may result in the associated charges becoming your financial responsibility. You are responsible for payment at the time of service for any form fee, deductible or co-payment as determined by your contract with your insurance carrier. Due to new billing regulations, your bill at the time of service is our best estimate of the total charges, however upon completion of documentation, follow up, and care coordination is when the final level of your visit will be determined. Please bring your insurance card to each visit.
It is your responsibility to present your insurance card to the office at every visit, if you do not present your insurance card and Pediatric Associates is unable to verify my coverage, you are responsible for the payment of services rendered to the patient at the time of service.
If your insurance terminates or changes during treatment and you do not notify Pediatric Associates in a timely manner, you are responsible for payment of the visits during the non-coverage period.
Assignment and Release:
The Responsible Party acknowledges insurance coverage and gives direct assignment to Pediatric Associates of Western CT for medical benefits and for payable services rendered. You authorize the release of information necessary to secure proper payment of benefits and the use of signature on all insurance claims. You authorize the insurer to pay any benefits directly to Pediatric Associates of Western CT, the full and entire amount of the bill incurred by myself to the named patient(s); or, if applicable any amount due after payment has been made by my insurance carrier. The Responsible Party is financially responsible for all charges.
- You are responsible for payment at the time of service for any form fee, deductible or co-payment as determined by your contract with your insurance carrier.
- If your child is being seen for a check-up and an issue/problem is found or discussed, there will be an additional fee/code charged with the preventative code. This will be subject to your co-pay/deductible per your insurance plan.
Any bill over ninety (90) days past due may be subject to collection procedures.
If you need to make payment arrangements, you may contact the billing office and we will be happy to assist you. All payment agreements must be followed through within the allotted timeframe, in order to stay current.
Our goal is to accommodate all of our patients’ healthcare needs. Missed appointments are detrimental to us and to our patients who could have been seen during the time set aside for your child’s appointment. We require 24 hours’ notice for our cancellation policy. There is a $25.00 fee for any missed or cancelled appointments with less than 24 hours’ notice.
Returned Check Fee: There is a $30 return check fee.
Form Fee: We have a designated team to handle all of your school, sports, camp, and daycare form needs. There is a $10 Form Fee for all forms, any form that needs to be completed within 2 business days will have an increased fee of $15.00.