office policy

Thank you for choosing All4Kidz Pediatrics as your child’s pediatrician’s office. As our patient we would
like to inform you of our current office policies. We understand that this form is lengthy, but understanding
these polices will help prevent issues in the future. Once you have carefully read the following, please
sign this document either online during check in or sign and return it to our office. If you have any
questions, please do not hesitate to ask one of your staff members.

Financial Policies
1. Most plans have co-payments, deductibles, and/or coinsurances that are your responsibility at the
time of your appointment. You or the authorized adult accompanying your child is responsible for
full payment of the bill at the time of service. We accept cash, Visa, MasterCard, and Discover. If
a check bounces you will be charged an additional fee of $35.00.
2. It is your responsibility to provide us with the most current insurance in formation. If the insurance
information you present is outdated or incorrect, you will be responsible for the full cost of the visit
and to submit the charges for reimbursement to the correct insurance plan.
3. Your insurance contract is between you and your insurance carrier. The benefit packages
provided by insurance companies vary from plan to plan. While we make an effort to verify your
coverage, we are not liable that the information given to us by your insurance is correct. It is your
responsibility to know what services may or may not be covered by your insurance. Any service
that is performed, but not covered by your plan, will be your responsibility. Please note: We will
not change our diagnosis to allow coverage.
4. Certain policies require you to select a Primary Care Physician (PCP). Please call your insurance
provider before your visit and select our practice; if they have not been notified, you may be
financially responsible for your appointment and/or your appointment will be rescheduled.
5. If you are insured by a non-participating carrier, we still expect payment from you at the time of
service, and you are responsible to submit any claims to your insurance company for
reimbursement. We will provide information to assist you in this process.
6. You are responsible to know your benefits and if you require referrals for specialist visits.
Referrals and prior authorization for services and medications require at least 3 business days to
complete.
7. Any balance over 60 days may be forwarded to a collection agency.
8. We are happy to complete forms for school, camp, etc. We charge $35.00 for sports physical if
not covered by insurance, $25.00 for FMLA paperwork. Payment is due when the forms are
dropped off. We provide vaccination card for free, but the turnaround time for forms varies based
on what type of form is needed. Please ask our staff when your specific form will be available. If
your child has not had a physical within the last year, please schedule an appointment so that we
can complete the form with current information.

Scheduling Policies

1. Before scheduling your child’s annual physical appointment, we recommend contacting your
insurance company to familiarize yourself with the services that will be covered at this type of
appointment. Not all plans cover immunizations, vision and hearing screens, urine screening,
questionnaires, flu shots as well as the physical exam itself. It is your responsibility to know your
insurance benefits. If services are not covered, you will be responsible for payment at the time of
visit, along with any remaining balance from services performed that we are not covered by your
plan.
2. Please make sure that if you have coordination of benefits (COB) with your insurance, your
insurance will deny all payments. It is advised that you call your insurance and complete COB
questionnaires. If this has not been done, we may reschedule your appointment. It will also be
your responsibility for services rendered on that day if insurance denies claims due to
coordination of benefits (COB) not being done.
3. Well and sick visits: Your insurance policy may cover well and sick visits differently, so you must
familiarize yourself with your coverage. For example, your policy may cover 100% of the cost of
well visits, but sick visits may include co-insurance, deductibles and/or a co-pay. If your child is
sick during a well visit and needs medical attention and/or treatment, your provider may bill the
insurance company for both a sick and well visit. Additionally, the provider may reschedule the
well visit and treat the sick issue instead. In this case, please be aware that you will be
responsible for your portion of the sick visit depending on your benefits.
4. If you are unable to keep your scheduled appointment, we require you to contact our office within
24 hours before your appointment to reschedule or cancel. This will allow us to have another sick
patient who needs appointment to come in. Continuous no-shows without calling to cancel may
result in a fee and/or dismissal from the practice.
5. We understand that your time is valuable. We make every effort to see all patients on time. In
order to provide you with prompt service, we need you to arrive 10 minutes to your schedules
appointment to answer some questionnaires that can be done only in person. We also urge to
finish the online check in process as this will greatly reduce your wait times and expedite the
patient workflow.

Divorce/Separation Policy:

The providers and staff of All4Kidz Pediatrics are focused on the medical, emotional, and psychological
health of your child(ren) – NOT legal issues involving divorce, custody, or separation agreements. That is
why we ask you to read the following:
1. Please make decisions regarding vaccinations, reproductive education, circumcision, etc. prior to
your appointment.
2. Either parent/legal guardian is allowed to schedule appointments, accompany the child and/or
obtain copy of visit summaries. Unless there is a court order in our records that restricts a
parent’s rights, please do not ask us to restrict the other parent’s involvement.
3. We will collect full payment (deductibles, co-pays, etc.) at the time of service from the parent
accompanying the child. If the divorce decree requires the parent not present to pay a part or the
entire bill, the authorizing parent is responsible for collecting payment from the other parent. We
will not collect payment from the other parent for you.
4. Both parents/legal guardians are allowed to sign an “Authorization for Medical Care” alternate
caregiver consent form. This means the other persons (such as nannies, grandparents, etc.) can
be authorized to accompany your child to appointments and consent for treatments. Both
parents/legal guardians are allowed to see the names of authorized persons on each other’s
forms. Unless instructed by the Court, please do not ask us to eliminate any names on the other’s
form. If you have legal concerns regarding a certain authorized person, please refer these
requests to your lawyer.
5. Additionally, we will not:
- Call to inform the other parent of appointments or to ask for consent prior to
treatment.
- Restrict either parent’s/legal guardian’s involvement in your child(ren)’s care,
unless authorized by law
- Tolerate appointment scheduling/cancelling patterns between parents.
6. Should issues between parents disrupt our practice or impede the care of your child(ren), we
reserve the right to discharge your family from further treatment.

Please call our office if you have any questions regarding our policies. Most problems can be
resolved quickly and your call will prevent misunderstandings. If you have trouble paying a bill,
please discuss the situation with us and arrangements can be made. Financial considerations
should never prevent children from receiving the care they need at the time that it is needed.