Renaissance Pediatrics Financial Policy

Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance and co-payments for participating insurance companies. Renaissance Pediatrics accepts cash, personal check, Visa, and MasterCard. There is a service charge for returned checks of $35.00.

Patients with an outstanding balance of 60 days overdue must make arrangements of payment prior to scheduling appointments. We realize that people have financial difficulty. Therefore, we may advise that due to your financial situation you seek your child's immunizations through a clinic or health department.

Insurance:

We bill participating insurance companies as a courtesy to you. You are expected to pay your deductible and co-payments at the time of service. If we have not received a payment from your insurance company within 45 days of the date of service, you will be expected to pay the balance in full. You are responsible for all charges. We do bill secondary insurance companies as a courtesy to you.

Your time of service receipt includes all information necessary for submitting claims to your insurance company.

If you need assistance or have questions, please contact the Billing department between 8:00 a.m. and 4:30 p.m. Monday through Friday at (757) 967-9750

Refunds:

Overpayments will be refunded upon written request to the responsible party within 30 days.

Managed Care:

If you are enrolled in a managed care insurance plan, (i.e., HMO), you must receive a referral from our office before seeing a specialist. NO retroactive referrals will be given

MISSED APPOINTMENTS/LATE CANCELLATIONS:

Broken appointments represent a cost to us, to you and to the other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed or late-cancelled appointments. Excessive abuse of scheduled appointments may result in discharge from the practice.

I have read and understand Renaissance Pediatrics Financial Policy. I agree to assign insurance benefits to Renaissance Pediatrics whenever necessary. I also agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collections.

Signature of insured or Authorized representative: ________________________

Patient Name: ____________________Patient D.O.B.____________________

Date: _________________________