ABC Pediatrics Office Policy

Office Policy

• Late Policy- If you arrive 15 minutes past your appointment time, we will attempt to work you into the schedule, but your appointment may need to be rescheduled.
• No Show Policy- Appointments must be canceled 1 hour prior to appointment for sick visits and 1 day prior for well child care and ADHD rechecks. There is a $25 fee for no-show appointments for well child care and ADHD rechecks. If you have 2 "no-shows" you will be reminded of our no-show policy and on your 3rd "no-show", you may be dismissed from the practice.
• Vaccine Policy- Vaccine records are required for all new patients. ABC Pediatrics Clinic recommends all patients be vaccinated on schedule per CDC guidelines.
• Transfer Policy- Once you change PCP or transfer records to another provider, you will be inactivated in our system and no longer be an active patient of ABC Pediatrics. We will provide a copy of your immunization record, growth charts, labs, last well child visit and consultation reports free of charge. Any additional copies of your record are available for $25 for 0-20 pages plus $0.50 per additional page.
• Forms- There is a $5 charge for vaccine records, or a copy of any office encounter not requested at the time of the visit. Any forms not presented during the office visit, (including camp forms, sports physicals asthma action plan, school notes and ect.) will be charged $10. Vaccine records can be obtained for free on the portal. Family and Medical Leave Act forms are $25. We require minimum 5-7 day turnaround time for any requested forms. If the form is needed in 2 days or less, an additional rush fee of $10 may apply.
• Release of Records- All medical record requests must be submitted in writing. We will complete your request within 7 days. You may receive one copy of your medical record at no cost. Any additional or future copies of the medical record will incur a charge of $25 for 0-20 pages plus $0.50 for additional pages per copy. There is no charge for sending these records when transferring care to a new physician's office.

I have read and understand this office's policies regarding appointments, no-shows, vaccination records, vaccination requirements, forms and transfer to another provider.

           Initials: ______

Financial Policy

• I understand that the accompanying parent or adult is responsible for any payments due at the time of service.
• I understand that I am financially responsible for any balance not covered by my insurance.
• Self-Pay patients and patients with health sharing plans are required to pay in full at the time of the visit. ABC Pediatrics will provide an invoice for submission to health sharing plans upon request.
• I authorize ABC Pediatric to release information as required to my insurance company or third -party payer for the purpose of determining benefits.
• If during a routine well exam, a new problem or chronic Issue Is Identified, discussed and/or additional testing, medication management or referral is required that goes beyond the scope of the routine well check up, my insurance company may require the payment of a co-pay, deductible or co-Insurance. Payment will be expected at the time of the visit or when your statement Is received.
• I understand that before making an annual physical (well child) appointment I will check with the current insurance carrier regarding covered and non-covered charges. Not all plans cover annual hearing, vision and other screenings. If it is not covered, it is understood that I will be responsible for payment of the allowable amount at the time of visit or upon receipt of a statement.
• I understand that once my health insurance has processed my child's claims, I will receive an Explanation of Benefits (EOB) from my insurance company. The EOB will show any balance due that becomes my financial responsibility.
• I agree that if payment is not made within 30 days of the billing statement issued to me, then I will not be able to schedule any further routine well appointments until the balance has been paid in full or arrangements for payment have been made.
• A $15 late fee will be added to the patients account if the balance is not paid within 30 days of receiving the second (2nd) outstanding balance notice.
• If I have an outstanding balance due at the time of a sick visit, payment arrangements will be made at the time of scheduling or before services are rendered.
• If payment by my insurance is denied due to my failure to provide coordination of benefits (COB), I will become responsible for all fees charged until I have provided the requested information to my insurance company and request they reprocess the claim.
• Balances outstanding longer than 90 days from the first billing statement may be sent to a collections agency and may result in dismissal from ABC Pediatrics if unpaid.
• A $20 fee will be charged on any checks returned for insufficient funds.

The accompanying parent or adult is responsible for full payment at time of service. In case of divorce, I will not place ABC Pediatrics in the middle of disputes. It is my responsibility to arrange for payment of my child's medical care. If I find myself in financial difficulty preventing timely payment on my account, I will contact the billing department at ABC Pediatrics to ask for assistance in payment arrangements on my account.

Initial : ______

Insurance Plans

• I understand that it is my responsibility to keep ABC Pediatric updated with the correct insurance information. Inaccurate or untimely Information provided to our staff that results in denial or noncoverage by your insurance company will result in the guarantor being responsible for the payment.
• It is my responsibility to understand the patient's benefit plan, including coverage for procedures and vaccines. It is my responsibility to inform ABC pediatrics if vaccines are not covered BEFORE vaccines are given. ABC Pediatrics will attempt to verify coverage prior to well child appointments, but information provided by the insurance company is neither binding nor definitive proof of coverage and may change prior to or after your appointment.
• Upon arrival, I will come prepared to present the proper insurance card at every visit to verify that ABC Pediatric Clinic has the most updated card on file.
• If the insurance card/plan presented is incorrect or invalid, I will be responsible for payment of the visit and I will be responsible for submitting the charges to the correct plan for reimbursement.
• If the proper insurance carrier has not been informed that ABC Pediatric Clinic or one of its providers is the primary care provider, then the visit must be paid in full or the visit must be rescheduled.
• I am authorizing ABC Pediatric Clinic to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such care to third party payers or my health insurance. I authorize my insurance plan to make direct payment of medical benefits, to include major medical benefits, to ABC Pediatric Clinic.

Initial: ______

Consent for Release of Immunization Records to Authorized Entities

I understand that, by granting the consent below, I am authorizing release of the child's immunization information to Texas DSHS and I further understand that DSHS will include this information in the state's central immunization registry ("ImmTrac"). Once in ImmTrac, the child's immunization information may by law be accessed by:

• A public health district or local health department, for public health purposes within their areas of jurisdiction;
• A physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient;
• A state agency having legal custody of the child
• A Texas school or child -care facility in which the child is enrolled
• A payer currently authorized by the Texas Department of Insurance to operate in Texas

regarding coverage for the child.

• I understand that I may withdraw this consent to include information on my child in the

ImmTrac Registry and my consent to release information from the registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group- MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.

By my signature, I grant consent for registration. I wish to include my child's information in the Texas immunization registry.

Initial: ______

Telemedicine Consent

• I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As always, your insurance carrier will have access to your medical records for quality review/audit.
• I understand the telemedicine process including the video conferencing technology, and that I may ask the provider any question regarding the telemedicine consultation, including the risks, benefits and alternatives
• I understand that a limited physical examination will occur during the telemedicine consultation, and I may elect to discontinue the consultation at any time without affecting my right to a future telemedicine consultation
• I understand that there are alternatives to a telemedicine consultation, and I may elect, at any time, for a direct in office evaluation.
• I understand that the transmission of medical information could be interrupted or distorted during the consultation due to technical difficulties.
• I understand that the video picture or any information may not be transmitted clearly to render an accurate determination; and the provider may recommend a follow-up visit at the medical office, or an urgent care center or emergency facility.
• I understand that not every medical condition should be evaluated using telemedicine;

escalating medical conditions should be evaluated by direct contact with a provider

• I understand that I have the right to withhold or withdraw my consent to the use of

telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing by contacting ABC Pediatrics at 361-853- 3222. As long as this consent is in force (has not been revoked) ABC Pediatric Clinic and its providers may provide health care services to me via telemedicine without the need for me to sign another consent form.

• I understand that I will be responsible for any copayments, coinsurances, or deductible that applies to my telemedicine visit. If my insurance does not cover telemedicine, I understand I will be responsible for the balance.

Initial: _____

I have read and fully understand these office policies in their entirety.

Patient's Name: _______________________________________________DOB: ___________

Responsible Party Member’s Name: ______________________Relationship: ______________

Responsible Party Signature: ______________________________________ Date: _________

Siblings Names: _______________________________________________________________

A copy of this policy is available on our website at www.abcpeds.net 

August 2023 version