Consent to Treat, Assignment of Benefits and Financial Policy Form

Thank you for choosing Cottonwood Pediatrics as your child’s healthcare provider. We are committed to providing the best medical care possible for your child. Please review the following policies.

Consent to Treat: By signing, you consent to treatment in our office or in the hospital. This includes any examinations, tests, immunizations, or other procedures which may be deemed advisable or necessary. You will be notified of any such testing and you have the right to an explanation of any procedures and their risks, benefits, alternatives, and charges before they occur. Your signature here consents to these procedures. It is your responsibility to inquire about and/or decline any such procedures. The occurrence of a procedure indicates that you understand the risks and benefits and have received a satisfactory response to your questions, if any.

Insurance: If the patient is covered by an insurance plan with which we contract, we will adhere to the terms of that contract and will file your insurance claim for you. By signing below, you

• allow us to file this claim for you and assign all insurance benefits arising from the claim to be paid directly to our office.
• accept responsibility for any charges not covered by your insurance plan and which are legally billable to the insured; you accept full responsibility if your insurance is terminated or otherwise invalid.
• grant us permission to file an appeal on your behalf (in accordance with applicable law) if the insurance company denies or restricts payment.

If the patient is covered by a plan with which we do not participate, we may provide you with the necessary documentation to file your own claim for reimbursement, and you are expected to pay for care your child received.

If your plan requires any authorization (prior or otherwise) for any service, whether at our office or elsewhere, we will assist you as possible, but the final responsibility for such authorization lies with you.

Financial Policy: Payment of your bill is required by contracts with insurance companies and government entities.

Payments: All applicable co-pays, personal balances, both current and prior, are due at time of service. Charges for our services in the hospital, in-patient, out-patient, or Emergency Room are due and payable upon receipt. We accept cash, check or credit cards. You agree to give us ALL active health insurance cards or policies for your child.

Usual and Customary Rates: We are committed to providing the best treatment for our patients and we charge what we believe to be reasonable and customary fees for our region and specialty. If your insurance company uses a different fee schedule, you will be responsible for any balance remaining. You will be financially responsible for ANY non- covered services, Medicaid or otherwise, performed on your child’s behalf by any staff at this office.

Past Due Accounts: Overdue accounts will be referred to a collection agency. Legal and/or collection fees that we pay to secure past due balances will be added to your account.

Account Balances:

• Payment of co-pays is expected and must be paid at time of service.
• If a payment agreement is used, ALL account balances must be paid within 90 days from the date of first statement. Once an amount is over 90 days in arrears, that amount will be required before patients can be seen. No further notices beyond statements within 90 days will be sent.
• Balances over $500 for inpatient services from our providers at another facility (such as Newton Medical Center) must be paid in full within 6 months from the date of the first statement. If over 90 days in arrears, that amount will be required before patients can be seen. No further notices beyond statements within 90 days will be sent.

Bad Checks: Checks returned as unpaid by your bank carry a $30.00 fee in addition to the amount of the check.

Policy on Missed Appointments: If you miss 3 appointments in a year without canceling, your account is blocked and you go to walk-in status until you have walked in 3 times. LATE MORE THAN 10 MIN is a MISSED APPOINTMENT. If we have appointments, we may arrange to see you later. If you need further information on this policy, please call.

I have read the above statements and accept full responsibility for the listed items.