9217 U.S. Hwy. 42 - Prospect, KY 40059
Phone: 502.228.1312 | Fax: 502.228.5541
A division of ONE Pediatrics, PLLC
Upon registration we ask each patient/guardian to complete our "patient registration form". This allows us to gather appropriate information necessary for filing insurance claims on your behalf. Therefore, we will need to copy your insurance card. This form will be used as permission for such purposes as release of medical information for insurance filing purposes, release of information to consulting physician or surgery specialist.
The fee for completing forms that are not filled out at the time of appointment will be $10.00, excluding immunization certificates.
Your "HEALTH INSURANCE" is an agreement between you and your insurance carrier to pay for medical care. Our office will file insurance as a courtesy to you. Of course, whatever balance remains, or is not covered by your insurance becomes your obligation to Prospect Pediatrics. As you are aware "red tape" frequently interferes with prompt insurance payment. Should a significant delay in insurance payment occur, we ask that you be responsible for paying the bill to our office. All co-pays are expected to be paid at the time of the visit, as well as any % which is patient responsibility.
Are always a dilemma for both the patient and the physician. As the patient it is your responsibility to obtain a referral for any consultation, testing, x-ray, emergency care or surgery if it is required by your insurance plan. We will assist with obtaining the referral as your primary care physician. If you of your own volition seek care from a specialist or consulting doctor you must call us and let us know when your visit is scheduled so that a referral is processed. We will expect to receive 48 hours advanced notice of an appointment. Failure to obtain this referral prior to the service will allow your insurance company to deny the claim (not pay). In this event you will be responsible for the office visit and lab work. If you need to go to the emergency room or immediate care center you must contact our office within 24 hours so that we can process a referral for your visit.
We are well aware that many of our patients have been involved in this legal situation, however it is a private issue not a health care one. We will expect that the parent who represents himself or herself as the custodial parent/guarantor will be responsible for the payment of the bill. We do not involve ourselves in any personal/legal disputes between our patients/guarantors. We will only bill the parent who is obtaining the care for their child. If you wish for the other parent (not signing for care) to be responsible for the payment it is your responsibility to obtain payment for yourself, our office only has a financial agreement with you as the custodial parent/guardian.
When you receive a statement in the mail you will know the balance owed is now your responsibility. You will be responsible for any "NCS" (non covered service) denied by your insurance carrier.
We hope that we have covered any financial questions regarding our office policies. If, at any time you need to discuss financial problems, please speak with our office manager. We will always be willing to work with you on a payment plan as long as your intent to make payment is evident to us.
Please print, sign, and bring this document with you upon your first visit.