Policies

ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE

Payment is required at the time services are rendered. Copayments and deductibles are contractually set by the insurance companies based on the policy you and your family have chosen, and we are contractually bound to collect them. The person bringing the patient to the clinic for their appointment is responsible for paying the copayment, deductible, and any outstanding balances on the account at the time of service unless previous arrangements have been made.

TYPES OF PAYMENT ACCEPTED

On Call Pediatrics, PLLC accepts cash, Visa, Mastercard, Discover, and personal checks. There is a service charge for returned checks of $30. If there is a returned check on file, all future payments must be made with cash or credit card.

SELF PAY

On Call Pediatrics, PLLC will collect, upon check in, the expected cost for level of services. If any additional services are provided, for example, labs or x-rays, the cost will be collected at check out. There is a discounted rate for self-pay when paid in full.

OUTSTANDING BALANCES

On Call Pediatrics, PLLC makes every effort to collect what is owed to us, including engaging the services of a professional collection agency for unpaid patient balances. Therefore, if a balance goes unpaid for 120 days from the date of service, the account may be turned to a collection agency. If the account is turned to a collection agency, the guarantor will be responsible for paying all collection and legal fees. Once an account has been turned, the family will be dismissed from the practice. Additionally, previous unpaid balances must be paid prior to the next visit.

INSURANCE

As a courtesy to our patients, On Call Pediatrics, PLLC, will file all patient claims with participating insurances. The guarantor is responsible for paying the copayment, deductible, and any outstanding balances at the time of service. Any charges not covered by insurance are the responsibility of the guarantor. You may be expected to pay any charges the insurance has not paid within 45 days of the date of service.

AUTHORIZATION FOR MEDICAL TREATMENT

On Call Pediatrics, PLLC personnel are hereby authorized to administer any medical, diagnostic, or therapeutic treatment as may be deemed necessary or advisable. I have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances.

DISCLOSURE OF MEDICAL INFORMATION

I understand that my medical records and billing information are made and retained by On Call Pediatrics, PLLC and are accessible to office personnel. Medical information may be used and disclosed for operations, functions, and to other physician or healthcare personnel involved in the continuum of care. As required by Oklahoma law, On Call Pediatrics, PLLC may participate in digital health information exchanges with other health care provider members, in which we send patient data to a network system committed to securing the information and allowing your data to be available to another member who is providing treatment to you. Safeguards are in place to discourage improper access. On Call Pediatrics, PLLC and its medical staff are authorized to disclose all or part of my medical record to any insurance carrier, worker’s compensation carrier, or self-insured employer group liable for any part of On Call Pediatrics, PLLC’s charges and to any healthcare provider who is or may become involved with my care. Oklahoma law requires that On Call Pediatrics, PLLC advise you that the information authorized for use of disclosure may include information which may indicate the presence of a communicable or non-communicable disease, or related to mental health, or drug substance or alcohol abuse. By signing this agreement, you are consenting to such disclosure. On Call Pediatrics, PLLC personnel may release my general condition to family or friends who inquire about me by name.

ASSIGNMENT OF INSURANCE BENEFITS

I agree that physician benefits otherwise payable to the insured are to be made payable to the physician(s) responsible for my care. Any payment received for this period may be applied to any unpaid bills for which I am liable, subject to the rules of coordination of benefits. Refusal to authorize assignment of benefits will require payment in full by cash, check, or credit card at the time of service.

FINANCIAL RESPONSIBILITY

As consideration for the services provided, I (the patient or responsible party) guarantee payment for any amount due for such services provided by On Call Pediatrics, PLLC.

CERTIFICATION

I hereby certify that I have read each of the above statements. I have had each item explained to me to my satisfaction and have been offered a copy of this form as well as the notice of privacy practice. I further certify that I am the patient or duly authorized by the patient to accept the terms of this patient agreement. A photocopy of this document has the same effect as an original.