MUDDY CREEK PEDIATRICS 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.
- Current insurance card must be presented at check in for every visit. If the insurance company that you designate is incorrect, you will be responsible for payment.
- We will not bill another insurance carrier supplied at a later date, if it is past the timely filing period for that insurance company. If a child is insured by more than one insurance company, our office needs to have all insurance companies’ names on file.
- According to your insurance plan, you are responsible for any and all co‐payments, deductibles, and coinsurances. When we verify that your deductible has not been met, we will collect up to 75% of the estimated and expected amount that will be applied to your deductible. This amount is due at the time of service and any additional balance due will be billed to you after insurance has notified Muddy Creek that the amount has been applied to your deductible.
- Co‐Payments are due at time of service. Co‐payments are a contractual obligation between you and your insurance company. If a sibling is added to an appointment, they will have a separate charge and co‐payment collected if required by insurance.
- If your insurance company does not cover a service, the amount must be paid in full within 30 days of denial from the insurance company. If not insured, the amount must be paid in full within 30 days from date of service. If you have no insurance, payment for an office visit is to be paid in full at the time of service. A 30% discount is given if the visit is paid in full on the day of the appointment.
- Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered. It is your responsibility to understand your benefit plan, including needs for referral or authorization for specialty care, vaccine coverage, lab tests and other services that may be required. Please note: physicians follow accepted national guidelines when determining your charges. They must code based upon what services were provided and cannot take into account particular health plan benefits.
- We will provide you with an itemized statement each month when there is a balance due. We accept cash, checks, MasterCard, Visa and Discover. You may also use our patient portal to pay online. To register to make payments on line, visit www.muddycreekpeds.com or ask one of our staff.
- We will charge your account a $35 non‐sufficient funds charge if your check is returned to us for insufficient funds.
- We appreciate the difficulties involved in divorce and court orders. Muddy Creek Pediatrics will not participate in disputes between custodial and noncustodial parents. We will refer to the responsible party, who signs the financial policy, for reimbursement of any amounts owed to our clinic.
- Balances are due within 30 days of the first statement, unless prior arrangements have been made with the billing department. Please call if you have questions about your bill. Most problems can be settled quickly and easily, and your call will prevent any misunderstandings.
- Staff will be collecting payments at check in on all accounts with balances that are more than 30 days past due. If you are having difficulty paying your bill, please discuss the situation with the billing department.
- Should your account remain outstanding more than 90 days, a final letter will be issued. Balances not paid in full within the 10 days of the date on the final request letter may be forwarded to a collection agency.
- Past Due Accounts: If your account becomes past due, we will take the necessary steps to collect the debt. We will make every attempt to set up payment arrangements with families that are going through a financial hardship. If we have to refer your account to a collection agency, you may be charged additionally for any collection agency costs incurred. If we have to refer collection of the account to an attorney, you may be charged additionally for any attorney fees we incur, including court costs. Please note that if your account is referred to a collection agency or an attorney for collection, the physicians of Muddy Creek Pediatrics may no longer be able to provide care for your family. In this case the guarantor of the account will be notified of this by certified mail and will be given adequate time (30 days) to find a new medical provider.
- Please notify us as soon as possible if you need to cancel an appointment since someone else may want the time slot reserved for you. A charge will be billed to your account for missed appointments not cancelled 24 hours in advance. The charge will be based on the type of appointment and the amount of time allotted for the appointment, and could be as much as $75, and will be charged per patient scheduled. We will attempt to notify you of an appointment within 48 hours of your scheduled visit, but ultimately, it is your responsibility to call us to cancel if you cannot keep your scheduled time. Should missed appointments become habitual, the physicians at Muddy Creek Pediatrics may choose to no longer care for your family. In that case, the guarantor of the account will be notified by certified mail and will be given adequate time (30 days) to find a new medical provider.
- After hours phone calls for prescriptions: For non-emergent issues of prescription refills, we ask that you please call during regular office hours, otherwise a charge of $20 may be billed to you.
- Forms and letters: We are happy to fill out school, camp, sports, day-care, medication, and other forms at the time of the well child visit. It saves us time to fill out these forms as the visit is being completed and the chart is open. Please give these forms to the medical assistant at the beginning of the visit. There will be a $5 charge for forms filled out at other times, payable when the form is picked up. There will be a $15 charge for the completion of FMLA papers. We ask that you allow 24-48 hours for the completion of all forms that are presented at any time other than at the well child visit.
- Records: The charge for record transfer will be made per child in accordance will State of Ohio Records . There is no charge for records faxed to specialists. All account balances will be collected before records are transferred.
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