Financial Agreement

Terms of Financial Agreement with ADVANCE PEDIATRICS, PLLC.:

Verification of eligibility and benefits are conducted every time you have an office visit, however, per your insurance carrier, this is not a guarantee of payment. Please be advised that you may be subjected to a deductible, co-insurance amount or co-payment responsibility which we may not be aware of until the claim for the office visit has been processed by your insurance carrier. Should there be a remaining balance due after your insurance has processed the claim, a statement will be sent to you for payment. Also, please be advised that failure to provide correct, new, or additional insurance information in a timely manner may result in additional financial responsibility on your part, this includes any private insurance coverage as well as AHCCCS.

understand that I am obligated to provide payment for any medical services through this office. I understand that while insurance may cover some of my expenses, I will be personally responsible for anything not handled by my insurance.

By signing this document, I am authorizing my insurance to cover any expenses attributed to Advance Pediatrics, PLLC.

I agree to cover any co-pay/ Deductible or Co-insurance at the time of the visit. I will pay any bill received within 30 days time. I understand that any failure to pay will result in a non-refundable late fee charge of $20 and the account will be forwarded to the Collection Agency after 60 days.

Itemized bills can be requested from the office. I understand that it is my responsibility to understand the coverage and limitations of my insurance. By signing this document, I am certifying that all of my billing is correct including my address phone number, and email. I will provide a copy of my insurance card and license/ photo ID when returning this document to the front desk.