The following disclosures are made in compliance with the Federal Truth in Lending Law.
Parent/Child: The parent/legal guardian accompanying the child is responsible for payment at the time of service including co-payment. The parent/legal guardian with whom the child resides is the person who will be billed for services rendered – which may include: deductibles, co-pays, and any non-covered services provided. The parent/legal guardian is responsible for any balance after insurance has paid.
Insurance: It is the responsibility of the parent/legal guardian to know what is covered and excluded from his/her plan for their child. You will be asked to present your insurance card at each visit. If this information is not provided the balance will be the financial responsibility of the parent/legal guardian for that child. Your co-payment is expected at time of service. We accept all payments made from insurance companies. If there is an overpayment made fro either the parent/legal guardian or insurance a refund will be processed. We will submit claims to your secondary carrier as a courtesy.
Private Pay: We ask our patients without insurance to pay in full at the time of service. We offer a Sliding Fee Discount for services rendered in our clinic to all who are uninsured or underinsured based on income and family size only (see guidelines and application below). All charges are due and payable within thirty (30) days from the date of the closing statement.
Divorce Decrees: Siskiyou Pediatric Clinic, LLP is not a party to your divorce decree. The responsibility for the minors rests with the accompanying adult. We will not be involved in mediating financial arrangements between parents/guardians.
Other Charges: We reserve the right to apply a billing charge of $7.00 per month to your account for balances that accumulate for more than sixty (60) days. This charge is automatically applied to parents/legal guardians that are on budget agreement. A $25.00 fee will be added to your account for any checks returned due to a non-sufficient fund (NSF). If we received a NSF, Siskiyou Pediatric Clinic, LLP will no longer accept checks for payment – only cash or credit/debit cards. We charge $5.00 for forms filled out by the physician if not completed by the parent/legal guardian at the time of service. All of the above charges will not be submitted to insurance.
We accept checks, cash, money order, Visa, MasterCard and Discover for payment.