Patterson and Tedford Pediatrics Financial Agreement and Consent
We are committed to providing your family with the best possible pediatric care. Your signature at the end of this
document will indicate that you have read, understand and agree to the policies outlined below.
UPDATE YOUR CONTACT INFORMATION: We depend on accurate information for emergency contact and for billing.
If you move, change your e-mail, or telephone number please inform the front desk so we can update our data base.
BILLING YOUR INSURANCE:
Please present your current health insurance card at each office visit. If you present an incorrect card, you must pay PTP
for the visit and submit your own claim to the correct plan.
If you have No Insurance then payment in full is required at the time of service.
Our office will bill validated Primary Insurance as a courtesy. You must pay for any patient responsibility.
Know your insurance and REMEMBER: Non-covered services such as vaccines can be VERY EXPENSIVE.
PAYMENT FOR SERVICES:
Co-pays, co-insurances, and deductibles must be paid at the time of service.
We mail statements on the 5th of each month, or the next business day. Payment in full is due by the 30th.
We require a valid credit card be kept on file to cover any past due balance. Please see the back of this sheet.
We accept cash, checks, money orders, Visa®, MasterCard® and debit cards with these credit logos on them.
We offer an Online Payment option through a secure website: https://pay.instamed.com. Our provider ID is pat.ted.peds
RETURNED CHECKS: The charge for a non-sufficient funds (NSF) check is $25. You must pay in full for the NSF check
and NSF fee within 10 days of notice. If payment is not received by the due date, we will forward the returned check to the
District Attorney’s office. It is a felony to knowingly write a bad check. For the next 12 months, cash or equivalent payment at
the time of service is required.
COLLECTION ACCOUNTS: When an account remains unpaid after 90 days we maintain the right to refer the account to an
outside collection agency. If your account is sent to a collection agency you may be asked to find another provider.
PARENTS NOT ATTENDING APPOINTMENTS: Arrangements for this need to be made with us in advance.
SEPARATED AND DIVORCED FAMILIES: Co-pays, deductibles, and co-insurances are due at the time of service.
Please provide us a copy of any court or mediation mandated requirements.
LATE ARRIVALS, CANCELLATIONS AND NO SHOWS: Please be considerate.
We require 24 hour notice to cancel or reschedule an appointment. For appointments scheduled within 24 hours of the
appointment time, 2 hour notice is required. Failure to give proper notice for cancellation or reschedule will result in:
o A $25.00 charge for the first missed appointment or late cancellation
o A $50.00 charge for the second missed appointment or late cancellation
o Potential dismissal from our practice for a third missed appointment
AFTER HOURS AVAILABILITY: A pediatric nurse is available for after-hour calls or emergencies for a fee of $32 that
insurance does not cover. Our doctors and pediatricians in our “on call group” provide back-up for the after-hours nurse.
COPIES OF MEDICAL RECORDS & OTHER FORMS: Records requests are generally fulfilled within 5 days.
When the request is addressed at the time of service there is generally no charge. When the request is more involved or does
not come during an office visit we charge a modest fee.
I acknowledge and understand the office policies and procedures explained above and have received a copy. I hereby authorize my
insurance company to pay PATTERSON AND TEDFORD PEDIATRICS directly. A copy of this authorization can be considered an
original for insurance purposes.
I do hereby consent to and authorize the performance of all examinations, treatments, and medical services by PATTERSON AND
TEDFORD PEDIATRICS and their staff, which may be deemed advisable. My signature on this document indicates that I have read,
understand and agree to the policies outlined in this document.
Print Name Relationship to Child(ren)
Child(ren)s Names and Dates of Birth :___________________________________________________
Patterson and Tedford Pediatrics Credit Card on File Policy
Your signature at the end of this document will indicate that you have read, understand and agree to the policies
As of January 2009, PTP requires a valid credit card be kept on file.
This policy is designed to:
Help you avoid all billing related fees
Streamline the billing process in our office and eliminate the expenses related to handling overdue accounts
Focus our time and energy on your children and their medical care
The card information is stored electronically in an encrypted form and cannot be viewed by our office staff.
Your signature will authorize the card to be used only when your balance becomes past due.
How the policy works:
1. At the time of registration or check-in, you will be asked for your credit card information to be electronically
stored in encrypted form in our computer. Only the last four digits are visible to our staff.
2. As before, we will bill your insurance carrier as a courtesy for all charges related to the visit.
3. When we receive an explanation of benefits (EOB) from your insurance we will send you a statement on the
fifth of the following month. If we have not received payment by the thirtieth of the same month, we will
charge the credit card on file for the balance due (on statement).
4. You are responsible to update our office if your address changes. If your mail is returned, your credit card will
be billed on the date on the statement we mailed.
5. If PTP attempts to use your card and it is declined or has expired, PTP will contact you by telephone, and you
will be responsible for updating our records.
Please remember that this policy does not restrict your right to appeal any charge made to your credit card. Should
you feel that we have charged your card in error, you may contact our billing office. If a mistake has been made
we will reverse the charges.
I have reviewed a copy of Patterson and Tedford Pediatrics’ billing policy and agree to provide my credit card
information to Patterson and Tedford Pediatrics for the sole purpose of payment for my child(ren)’s medical care.
Signature of Authorized User Date
Print Name as it appears on your Credit Card
CONSENT TO USE & DISCLOSE HEALTH INFORMATION
Patterson & Tedford Pediatrics
This office is required by Federal Regulations to inform our Patients in regards to the use of your child’s health information in accordance to Health
Insurance Portability & Accountability Act of 1996 or HIPPA.
PLEASE READ THE FOLLOWING CAREFULLY!
I understand that as part of my child’s health care, Patterson & Tedford Pediatrics originates and maintains paper and/or electronic records
describing my child’s health history, symptoms, examination and test results, diagnoses, treatments, and any plans for future care or
treatment. I understand that this information serves as:
A basis for planning my child’s care and treatment
A means of communication among health professionals who contribute to my child’s care.
A source of information for applying my child’s diagnosis and treatment information to my bill.
A means by which a third-party can verify the services billed to me actually took place.
I understand and have been provided access to a Notice of Privacy Practices that provides a more complete description of information
uses and disclosures. This notice is located in the waiting area in plain view. I understand that I have the following rights and privileges:
The right to review the Notice of Privacy Practices prior to signing this consent, allowing treatment, or making
payment for services rendered.
The right to object to the use of my child’s health information for directory purposes.
I understand that Patterson & Tedford Pediatrics is not required to agree to the restrictions requested. I understand that I may revoke this
consent in writing, except to the extent that the organization may refuse to treat my child as permitted by Federal Regulations. I
understand that Patterson & Tedford Pediatrics reserve the right to change their Notice of Privacy Practices. I further understand that
Patterson & Tedford Pediatrics uses a computerized state vaccine registry to track immunization requirements and maintain immunization
records. We will enroll your child unless you inform us in writing that you do not wish to participate.
Please note that I consent to the following uses of my child’s medical information
______ I allow my child’s immunization records to be fax’d or mailed to my child’s school.
______ I allow my child’s medical information to be released to: ______________________________
______ Other: ______________________________________________________________________
I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my
protected health information to another entity. I hereby consent to such disclosure for these permitted uses. I also hereby consent to such
disclosures via fax.
I fully understand and accept the terms of this consent.
CONSENT TO RELEASE MEDICAL INFORMATION
PHYSICIANS NAME AND ADDRESS: ________________________________
I, parent of _____________________________ authorize your office to release medical records to:
PATTERSON AND TEDFORD PEDIATRICS
A CALIFORNIA MEDICAL CORPORATION
7700 MORRO ROAD
ATASCADERO, CA 93422
Medical Records fax # 805-466-6603
PATIENT NAME: (please print)_______________________________________
DATE OF BIRTH:_________________________________________________
DATE:____________________ TELEPHONE # ( )_____________________