Common use of Minor Patients Clause in Contracts

Minor Patients. Regardless of marital status, we will look to the adult accompanying the patient for payment due at the time of service rendered to the minor patient. If a parent, other than the one accompanying the minor patient to the office, is legally responsible for medical charges, the accompanying parent will be responsible for payment as we are not a party involved in the divorce decree. We will provide a statement showing payment made that can be provided to the financially responsible adult for reimbursement. OTHER SERVICES REFERALS: Our office requires at least 48 hour notice to request a referral, unless the medical visit is a true emergency. It is the specialist responsibility to ensure there is a referral in place prior to your appointment, not our responsibility. Waiting until the day of the appointment and requesting that we do a referral could cause your appointment to be rescheduled and we regret we have to do this. Make sure your specialist has the referral prior to your arrival. It is the responsibility of the specialist to ensure they have a referral. MISSED APPOINTMENTS/ LATE CANCELATIONS/LATE ARRIVALS: Missed appointments represent a cost to us and a missed opportunity to for another patient to be seen during that time we saved for you. Chronic missed appointments can lead to “working you into our schedule” or being dismissed from the practice. Late arrivals that are more than 15 minutes late will possibly rescheduled based upon the description of the physician or practitioner. Habitual tardiness can lead to us determining the best time for our office to work you into the schedule. PRESCRIPTION REFILLS: Please allow 24-48 hours for refills. Refills will be addressed from Monday-Friday 8:30-4:00pm.If the refill comes in after 4:00pm, it will be addressed the next business day. Narcotic/controlled substances will not be filled on the weekend. Constant calling to see if your medication has been refilled will not speed up the process. Most prescriptions are done electronically and can be monitored by our office and software company to ensure compliance. We do not fill medication to last one year. We try to accommodate patient with cost, but we will not put refills on narcotics/controlled substances.

Minor Patients. Regardless of marital status, we will look to the adult accompanying the patient for payment due at the time of service rendered to the minor patient. If a parent, other than the one The parent or guardian accompanying the minor patient is responsible for the full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment. This office will not attempt to collect payment from a parent that is not present in the office at that visit. CONSENT & AUTHORIZATION: I voluntarily and knowingly request and consent to the officeservices, treatments and/or procedures recommended by the dentist and to all diagnostic methods deemed appropriate by the dentist which may include, but not be limited to, x-rays, study models, imagery, and other aids. I authorize the dentist to perform all such services, treatments and/or procedures and to utilize all such diagnostic methods. Further, I acknowledge and understand that the dentist may engage the assistance of others in performing such services, treatments and/or procedures and in utilizing such diagnostic methods. I understand that the practice of dentistry is legally not an exact science and I acknowledge that no guarantees have been made to me concerning the results of the services, treatments, procedures and/or diagnostic methods that have been recommended. I also understand that the use of anesthesia carries with it significant risks that have been explained to me. I acknowledge that any insurance coverage that I may have is based on a contract between my insurance company and me, my spouse and/or my employer and the dentist is not a party to this contract. Therefore, I acknowledge that ultimately I am fully responsible for medical chargesthe payment of any and all sums owed to the dentist for the services rendered on my child / children. As a courtesy to me, the accompanying parent dental office will bill my insurance company and I acknowledge that I will remain liable for any and all amounts not paid by the insurance company for any reason (including but not limited to the insurance company declining coverage after initially approving it) or if the insurance company fails for any reason to reimburse the dentist within 30 days after being billed by the dentist. I acknowledge that it is my responsibility to provide the dentist with my current insurance information and any changes thereto. All returned checks will be subject to a $25.00 returned check fee. Any account balances that remain unpaid for 30 days from the date balance is past due shall accrue interest at the rate of eighteen percent (18%) per year and may be referred to a collection company or attorney. In the event this occurs, I understand that I will be liable for collection costs. Further, in the event any unpaid account balance is referred to an attorney for collection, I agree also to be responsible for payment as we are not a party involved all costs and reasonable attorney’s fees incurred in connection therewith. I consent to the divorce decreedentist’s use and disclosure of my health information to my insurance company and any agent thereof. We will provide a statement showing payment made that can be I hereby assign to the dentist all of the insurance benefits due to me for the services, treatments, procedures and/or diagnostic methods provided to me and I authorize my insurance company to make payment directly to the financially responsible adult dentist for reimbursementthe costs associated therewith. OTHER SERVICES REFERALS: Our office requires at least 48 hour notice I further consent to request a referralbe contacted by the dentist, unless the medical visit is a true emergency. It is the specialist responsibility to ensure there is a referral in place prior to your appointment, not our responsibility. Waiting until the day any agent of the appointment and requesting dental office, or any collection agency (or agent thereof) or attorney to whom an unpaid account balance has been assigned or referred by mail at any address that we do I provide to the dental office and/or by facsimile, email or phone number (whether a referral could cause your appointment cell phone or landline) at any facsimile number, email address or phone number (whether a cell phone or landline) that I provide to be rescheduled and we regret we have to do this. Make sure your specialist has the referral prior to your arrival. It is the responsibility dental office or any agent of the specialist to ensure they have a referraldental office. MISSED APPOINTMENTS/ LATE CANCELATIONS/LATE ARRIVALS: Missed appointments represent a cost to us and a missed opportunity to for another patient to be seen during that time we saved for you. Chronic missed appointments can lead to “working you into our schedule” or being dismissed from the practice. Late arrivals that are more than 15 minutes late will possibly rescheduled based upon the description of the physician or practitioner. Habitual tardiness can lead to us determining the best time for our office to work you into the schedule. PRESCRIPTION REFILLS: Please allow 24-48 hours for refills. Refills will be addressed from Monday-Friday 8:30-4:00pm.If the refill comes in after 4:00pm, it will be addressed the next business day. Narcotic/controlled substances will not be filled on the weekend. Constant calling to see if your medication has been refilled will not speed up the process. Most prescriptions are done electronically and can be monitored by our office and software company to ensure compliance. We do not fill medication to last one year. We try to accommodate patient with cost, but we will not put refills on narcotics/controlled substances.Your Name (Printed):

Minor Patients. Regardless of marital statusFor all services rendered to minor patients, we will look to the adult accompanying the patient for payment, even if that adult is not the financially responsible party. Missed/Canceled Appointments Appointments must be canceled at least 24 hours prior. Repeated missed or canceled appointments may result in limitations on your ability to schedule multiple children to be seen at once, or to schedule appointments during high volume times of service. Severe abuse of this policy may result in dismissal from the practice. Payment and Collection Policies Our goal is to provide care to your child even if you are having financial difficulties. There is no charge for speaking to the physician over the phone, and a payment due plan for office visits can easily be set up. All children without insurance are eligible for free state-provided immunizations, which can be administered at the office. However, communication with the office is essential in order for Harmony Mills to continue this policy. In particular, if your insurance has a large deductible, this may not be visible to the office at the time of service rendered to check-in, and you would only be billed for your regular co-pay at time of service. In this situation, you would receive a bill for the minor patientbalance owed at a later time. Unless a prior arrangement with a written and signed agreement has been made with the practice manager, the insurance will be billed and then statements will be sent for any balance after your insurance plan pays its share. Payment is due upon receipt of this balance. If you believe there has been a parentbilling error, other than please contact the one accompanying office immediately. If you are unable to pay the minor patient entire balance, please contact the office immediately to the officeset up a payment plan. Failure to respond to two statements requesting payment may trigger collections action. Should that become necessary a 30% fee or $35 charge, whichever is legally responsible for medical chargesgreater, the accompanying parent will be responsible for payment as we are not a party involved in the divorce decree. We will provide a statement showing payment made that can be provided to the financially responsible adult for reimbursement. OTHER SERVICES REFERALS: Our office requires at least 48 hour notice to request a referral, unless the medical visit is a true emergency. It is the specialist responsibility to ensure there is a referral in place prior assessed to your appointment, not our responsibility. Waiting until the day of the appointment account and requesting that we do a referral could cause your appointment to be rescheduled and we regret we have to do this. Make sure your specialist has the referral prior to your arrival. It is the responsibility of the specialist to ensure they have a referral. MISSED APPOINTMENTS/ LATE CANCELATIONS/LATE ARRIVALS: Missed appointments represent a cost to us and a missed opportunity to for another patient to be seen during that time we saved for you. Chronic missed appointments can lead to “working you into our schedule” or being dismissed will result in dismissal from the practice. Late arrivals You will then be responsible for all fees due to the collection agency in addition to the balance owed. Laboratory Procedures All in-office lab work is sent to the local LabCorp facility for processing, along with the most recent insurance information we have on file for the patient. Harmony Xxxxx Pediatrics is not responsible for verifying if LabCorp accepts any particular insurance plan(s). In the event that procedures performed by the lab are more than 15 minutes late will possibly rescheduled based upon not entirely covered by the description insurance plan on file, you may receive a bill from LabCorp for all or part of the physician charges. Harmony Xxxxx Pediatrics has no jurisdiction over this process, and cannot intervene in the adjudication of such charges in any way; any questions or practitioner. Habitual tardiness can lead appeals should be directed to us determining the best time for our office LabCorp or to work you into the schedule. PRESCRIPTION REFILLS: Please allow 24-48 hours for refills. Refills will be addressed from Monday-Friday 8:30-4:00pmyour insurance provider.If the refill comes in after 4:00pm, it will be addressed the next business day. Narcotic/controlled substances will not be filled on the weekend. Constant calling to see if your medication has been refilled will not speed up the process. Most prescriptions are done electronically and can be monitored by our office and software company to ensure compliance. We do not fill medication to last one year. We try to accommodate patient with cost, but we will not put refills on narcotics/controlled substances.

Minor Patients. Regardless of marital statusFor all services rendered to minor patients, we will look to the adult accompanying the patient for payment, even if that adult is not the financially responsible party. Missed/Canceled Appointments Appointments must be canceled at least 24 hours prior. Repeated missed or canceled appointments may result in limitations on your ability to schedule multiple children to be seen at once, or to schedule appointments during high volume times of service. Severe abuse of this policy may result in dismissal from the practice. Payment and Collection Policies Our goal is to provide care to your child even if you are having financial difficulties. There is no charge for speaking to the physician over the phone, and a payment due plan for office visits can easily be set up. All children without insurance are eligible for free state-provided immunizations, which can be administered at the office. However, communication with the office is essential in order for Harmony Mills to continue this policy. In particular, if your insurance has a large deductible, this may not be visible to the office at the time of service rendered to check-in, and you would only be billed for your regular co-pay at time of service. In this situation, you would receive a bill for the minor patientbalance owed at a later time. Unless a prior arrangement with a written and signed agreement has been made with the office administrator, the insurance will be billed and then statements will be sent for any balance after your insurance plan pays its share. Payment is due upon receipt of this balance. If you believe there has been a parentbilling error, other than please contact the one accompanying office immediately. If you are unable to pay the minor patient entire balance, please contact the office immediately to the officeset up a payment plan. Failure to respond to two statements requesting payment may trigger collections action. Should that become necessary a 30% fee or $35 charge, whichever is legally responsible for medical chargesgreater, the accompanying parent will be responsible for payment as we are not a party involved in the divorce decree. We will provide a statement showing payment made that can be provided to the financially responsible adult for reimbursement. OTHER SERVICES REFERALS: Our office requires at least 48 hour notice to request a referral, unless the medical visit is a true emergency. It is the specialist responsibility to ensure there is a referral in place prior assessed to your appointment, not our responsibility. Waiting until the day of the appointment account and requesting that we do a referral could cause your appointment to be rescheduled and we regret we have to do this. Make sure your specialist has the referral prior to your arrival. It is the responsibility of the specialist to ensure they have a referral. MISSED APPOINTMENTS/ LATE CANCELATIONS/LATE ARRIVALS: Missed appointments represent a cost to us and a missed opportunity to for another patient to be seen during that time we saved for you. Chronic missed appointments can lead to “working you into our schedule” or being dismissed will result in dismissal from the practice. Late arrivals You will then be responsible for all fees due to the collection agency in addition to the balance owed. Laboratory Procedures All samples for lab procedures drawn in our office are sent out to Seton Health Laboratory for processing, along with the most recent insurance information we have on file for the patient. Harmony Xxxxx Pediatrics is not responsible for verifying if Seton Health accepts any particular insurance plan(s). In the event that procedures performed by the lab are more than 15 minutes late will possibly rescheduled based upon not entirely covered by the description insurance plan on file, you may receive a bill from Seton Health for all or part of the physician charges. Harmony Xxxxx Pediatrics has no jurisdiction over this process, and cannot intervene in the adjudication of such charges in any way; any questions or practitioner. Habitual tardiness can lead appeals should be directed to us determining the best time for our office Seton Health Laboratory or to work you into the schedule. PRESCRIPTION REFILLS: Please allow 24-48 hours for refills. Refills will be addressed from Monday-Friday 8:30-4:00pmyour insurance provider.If the refill comes in after 4:00pm, it will be addressed the next business day. Narcotic/controlled substances will not be filled on the weekend. Constant calling to see if your medication has been refilled will not speed up the process. Most prescriptions are done electronically and can be monitored by our office and software company to ensure compliance. We do not fill medication to last one year. We try to accommodate patient with cost, but we will not put refills on narcotics/controlled substances.