(513) 398-3900

6400 Thornberry Ct, Ste 610
Mason, Ohio 45040

Financial Policy


Thank you for choosing Muddy Creek Pediatrics. We are committed to providing the best care possible. This goal is best achieved by letting you know in advance of our financial policy, which is an agreement between the doctors of the practice and the child’s parent or guardian or a patient 18 years and older. Your clear understanding of the financial policy agreement is important to our professional relationship. Please read this carefully and if you have questions please do not hesitate to ask a member of our billing department. We require a signature to document that you have read and understand these policies.


We must emphasize that as pediatric providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility from the DATE SERVICES ARE RENDERED. Therefore, it is necessary for you to know the benefits your insurance plan provides for you.





We appreciate your compliance with these policies. We strive to provide excellent, cost effective medical care in an ever-changing health care environment. We are happy to discuss any questions you have about these policies.

The undersigned agrees with the terms and conditions listed in the financial policy. By refusing to sign this financial policy, I agree to pay in full at the time of service. I certify that the information I have given to Muddy Creek Pediatrics is accurate. I hereby authorize Muddy Creek Pediatrics to furnish my insurance company all they may request concerning the patient’s present illness or injury. I hereby assign to Muddy Creek Pediatrics all benefits for service rendered.



I have read and understand the Muddy Creek Pediatrics Financial Policy.  I agree to adhere to the above written policies, and all questions have been answered.



Children’s Names  (Please Print)



Parent Name (Please Print)                                                         Parent Signature