This is an agreement between Wake Forest Pediatric Associates, PLLC, as creditor, and the Patient/Debtor named on this form.
In this agreement the words “you,” “your,” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we,” “us,” and “our” refer to Wake Forest Pediatric Associates, PLLC.
By executing this agreement, you are agreeing to pay for all services that are received.
If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month.
You choose to pay your copay, deductible or account balance by __cash, __check, or __credit card on the day that treatment is rendered.
Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the end of the month.
Charges to Account
We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service.
Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.
You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a collection agency or credit bureau.
Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these.
Patients not covered by insurance are eligible for a discount if they pay for their visit at the time of service. The current discount is 15%.
There is a fee (currently $30) for any checks returned by the bank.
Missed Appointment Fee
All appointments that must be canceled require 24-hour advance notification to this office. Patients with three missed physical appointments will be asked to transfer their records to another doctor.
Waiver of Confidentiality
You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.
Transferring of Records
You will need to request in writing by completing paperwork in full to include parents name, address and phone number. You will also be asked to pay a reasonable copying fee as set by Healthport. Healthport is our medical record copying service.
We require written approval/authorization by your employer and/or worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.
If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. In addition to this verification, we require that you allow us to bill your health insurance. In the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient’s responsibility. We cannot bill your attorney for charges incurred due to a personal injury case.
Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force.