Office Policy 2021
Holly City Pediatrics, PA
January 1st, 2021, Revision
Thank you for choosing us as your primary care pediatrician! It is our #1 goal to provide you with the best care possible In order to provide your child/children with the best care possible, we have developed a guideline of policies and procedures. Though most of these policies have been in place for quite some time, we wanted to provide you with everything in one place, for your reference. Please read it over and sign at the bottom of the document. We would be happy to answer any questions/concerns that you have and provide you with a copy, at your request.
1. Insurance/Proof of Insurance:
a. Insurance card(s) must be available for verification at every visit, to ensure that all information is correct and up to date. If you are not to provide us with updated/correct insurance information, payment for the visit will be required up front. Making sure to update all of your insurance information, helps to ensure that you do not receive a bill for services that you have coverage for.
b. Though insurance eligibility will be verified by the office prior to every visit, it is parent/guardian’s responsibility to be aware of coverage and benefits. If you have any questions regarding your current benefits/eligibility, please contact your insurance provider directly.
c. If you have insurance coverage that requires that you choose a PCP, one of our Doctors must be listed prior to your visit at our office. Per our agreements with those insurance companies, we CANNOT see a patient without being listed as PCP.
d. If you do not have insurance coverage, payment for the visit must be paid at the time of service.
e. Motor Vehicle Accident related visits require claim information at the time of visit.
2. Co-payment:
a. ALL COPAYS MUST BE PAID AT THE TIME OF SERVICE. Failure to collect a patient’s copay could be considered fraud.
**In the event of split financial responsibility, due to divorce/separation, it is the responsibility of the party who is bringing the child to the office. We will not balance bill. **
3. Claims:
a. Our billing department will submit all of your claims and will help in any reasonable way that we can, to ensure that your claims are paid. There will be occasions that the insurance will require information directly from the parent/guardian/policy holder. In those circumstances, you will be contacted by our office and asked to comply with their request. Failure to do so will result in your account being frozen, until the issue is resolved.
b. Should you receive a bill for services at our office and have any questions/concerns, please contact the office directly.
4. No call, No Shows:
a. When possible, as a courtesy, we will attempt to reach you with an appointment reminder. Though we ask for 24 hours notice for appointment cancellations, we understand that life often doesn’t work that way. As soon as you know that you will not be able to make it in for a scheduled visit, please give us a call. If it is outside of normal office hours, our answering service will be available to take the message.
b. If no notice is given for a cancellation, parent/guardian will be charged $25.00 directly, per child on the schedule for that given date.
c. After two no shows, parent/guardian will receive a warning letter explaining the no show policy. Three or more no shows in one year, could result in a discharge from our practice.
5. Forms:
a. There is a minimum charge of $10.00 (please see form charge sheet for further pricing), in order for us to complete forms. Please understand that your form is one of many. We will do our best to have your form completed in a timely fashion, but there is a wait time of 2-5 business days.
b. Physical forms may be filled out at no charge, IF AVAILBLE AT THE TIME OF THE PHYSICAL EXAM. If a patient needs a physical form filled out, but is not due for a physical, the form will fall under the policy above.
c. In the event that a form requires additional testing or more up to date information, an appointment with the doctor may be necessary.
6. Referrals:
a. We cannot issue a referral if we didn’t refer to the specialist or if our doctor hasn’t seen the patient regarding the problem. There are very limited exceptions, so if you have any questions, please contact our office directly.
b. In order for us to complete an accurate referral, we must have the NPI number for the specialist that our patient is scheduled to see. A request will not be made for a referral, until we have that information.
c. To ensure that your referral is done prior to your visit with a specialist, please make sure to get all necessary information to us 72 hours before your appointment.
7. Medical Records:
a. All medical records are available, with written notice or record release, at any time. Records released directly to a parent/guardian, will have a charge of $1.00 per page, which will be charged in advance.
b. If you would like us to transfer your records to another physician, there will be no charge to you. Once a record release is filled out with our office or a release is received form your new physician, we will fax over all requested documentation.
8. Residents:
a. Since our doctors are a part of the Inspira Residency program, there may be times that a resident doctor will be with us. The resident will see you with, and under the supervision of one of our doctors, to complete their training in pediatrics. It is not required for you to see the resident, so please let us know if you would like to see the doctor alone.
9. Age Restriction:
a. All patients must be accompanied by an adult until the age of 18.
b. While we will perform continued care for ESTABLISHED patients until the age of 21, we will not take on any NEW patients 18 or older. PLEASE NOTE, this is on a situational basis and subject to change.
c. In the event that your child (16 years and up) develops adult complications, etc. our practice may recommend that you seek a family practice physician that is better equipped to address your medical condition(s).
*All policies/procedures are subject to change