Financial & Privacy Forms
Please download, read and sign our financial policy agreement and privacy notice.
- Financial Policy Agreement
- Notice of Privacy Practices (en Espanol)
- Self-Pay Acknowledgement
As a courtesy to our patients, we will gladly file the forms necessary so that you receive the full benefits of your medical coverage. We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company to pay for the services we have provided to you.
Copayments and Deductibles
Depending on your insurance policy, a copayment and/or deductible or coinsurance may be required at the time of service. Payment may be made in cash, by check or by credit card. We also accept Health Savings Account (HSA) cards for payment.
Please note that the copayment 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. Please see Health Insurance 101 for a better explanation of these terms.
Patients Without Insurance Coverage/Non-Covered Expenses
We are happy to work with families that prefer to pay directly for services or do not have insurance. For such patients, a time of service discount will be applied to the bill if settled in full on the day of service. This discount does not apply after the day of the visit. The same discount will be applied to any non- covered charges for patients with insurance, if paid at the time of service. This discount cannot be applied toward the “patient responsibility” portion of covered charges, as those charges are already discounted through the contract we maintain with your insurer.
Credit Card on File Policy
Decatur Pediatric Group is committed to making our billing process as simple and easy as possible. Effective January 1, 2019 we will require that all patients provide a credit card on file with our office. We will store your card number is a secure, compliant location separate from the electronic medical record. Credit cards on file can be used to pay copays and other charges at the time of the visit. We will also use the stored credit card for payments toward the patient responsibility after processing the visit with your insurance company, unless you make other arrangements within 13 days of being notified of a balance.
For families who do not wish to leave a credit card on file, you will be obligated to maintain a $100 balance, per child, with the practice. That balance will be used for any unpaid patient responsibility, as outlined above, and will need to be replenished before a member of the family can be seen in the practice again.
Sick Complaints at a Well Child Check-Up
Please note that your insurance covers preventative care as a bundled service. If you present to a scheduled check-up and your child is sick, or you’d like to address a chronic issue, we are obligated to file a separate visit code with your insurance plan — just as we would if you brought your child in for that complaint on any other day. As such, your regular copay, deductible, and/or co-insurance amounts will apply and payment will be expected at the time of service.