In order to obtain reimbursement for services provided to my child by Cincinnati Children's Liberty Primary Care, Cincinnati Children's Mason Primary Care or Cincinnati Children's Springdale Primary Care, I authorize disclosure of my child’s record for treatment, payment, and healthcare operations.
If my primary care physician is a participating provider in my insurance plan, I hereby assign medical benefits due be paid directly to Cincinnati Children's.
I understand that I am financially responsible for any unpaid balances for services if I fail to provide complete and current insurance information within 60 days of the date services are provided. If no Secondary Insurance information is provided, I attest and affirm that I have no other insurance other than that listed as Primary Insurance.
I understand that if my child’s account becomes past due, Cincinnati Children's will take necessary steps to collect the debt, including referring my account to an outside collection agency.
We follow the American Academy of Pediatrics schedule of visits for routine well child care. This schedule may not be the same as the one your insurance company follows. Additional services (listed below) are separate charges from the wellness exam and have separate fees. This is not an exclusive list of charges and other charges may apply.
Vision Screens; Hearing Screens; Urinalysis; Developmental Screenings (MCHAT) and Immunizations
Please be aware that a physician may bill an office visit (99212-99215) in addition to a previously scheduled preventative visit. Per CPT coding rules the well child visit code applies only to preventative medical care but does not include any issues related to chronic diseases or acute illness. Insurance companies process these claims according to their policy guidelines and the patient may have a balance due for the unrelated office visit. If your child comes in for a well-child visit, but in the course of the routine visit “an abnormality/ies is encountered or a preexisting condition is addressed” the appropriate office E/M service will be coded in addition to the preventative code. Examples of this would be patients with asthma and ADD/ADHD coming in for a well-child exam.
Newborn coverage is not automatic! Most insurance plans only allow 30 days after the baby’s birth to add your newborn to the policy. Please call your benefits department or your insurance company to add your baby to the policy right away. The first visit in our office is scheduled during the first week and is considered a “feeding/jaundice check” and is not billed as a well-child check. The first checkup in the office is at 2 weeks of age.
Insurance and Payments
At the time of your appointment you will be required to present a form of Identification and your current insurance card. This will be completed at each appointment. If you do not have a current insurance card, you can pay in full at the time of service or you may reschedule.
Payment in full is expected at time of service if we do not have a contract agreement with your insurance company and we are considered out of network providers.
Copayments and/or any non-covered service amounts are due at the time of service regardless of who brings the child to the appointment. There is an additional $15.00 fee if co-payments are not paid on the day the service is provided.
Our office accepts Visa, MasterCard, Discover and American Express. You will receive a bill for any “patient responsibility” and/or an explanation of benefits from your insurance carrier regarding your responsibility.
Payment plans - We recognize that there are times when you cannot pay your balance in full within the 30-day period. We offer payment arrangements for special circumstances. Please contact our Billing Office at (513) 336-6700 to set up a payment plan contract.
There is an additional charge billed to your insurance company for same day evening appointments, walk in appointments and “by the way” visits if you have a sibling seen who did not have an appointment scheduled. If this is not covered by your insurance company, you will be responsible for the charge.
In case of divorce or separation, the parents are responsible to follow the ruling of the divorce decree. We will send the statement to the parent that signed the Financial Policy.
Annual Form Fee
Cincinnati Children's charges an annual form fee of $25.00 per patient (maximum of $75.00 per family) to cover any forms filled out by our office, nurse triage and prescription refills. Insurance companies do not provide a benefit for these services, so we do require this fee. Examples are as follows, sports forms, daycare forms, medication forms. FMLA/Disability authorization forms are an additional fee of $25.00 per form.
Failed and Cancelled Appointment Policy
It has always been our practice and our privilege to care for our patients. However, when appointments are not kept, these time slots go un-used and our patients seeking appointment times are inconvenienced. If an appointment is made and not kept there will be a charge (as indicated below), not billable to insurance for that “non- visit”.
Our policy requires that you notify us at least 24 hours in advance if you need to cancel or reschedule an appointment.
CHARGES FOR CANCELLATION WITHOUT SUFFICIENT NOTICE AND FAILED APPOINTMENTS
- $0.00… First missed appointment or cancellation with insufficient notice.
- $50.00…Second missed appointment or cancellation with insufficient notice.
- $75.00…Third missed appointment or cancellation with insufficient notice.
I have read this Financial Policy and understand I am ultimately responsible for the charges incurred. This is an agreement between Cincinnati Children's and me, the patient or patient representative. By executing this agreement, I agree to pay for all services rendered.