Thank you for choosing Little Oak Pediatrics, LLC as your primary care provider. Our goal is to provide and maintain a good provider-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal. Please read this carefully and if you have any questions, please do not hesitate to ask a member of our staff.

1. On arrival, please sign in at the front desk and present your current insurance card at every visit. You may be asked to sign and date the file copy of the card. This is your verification of the correct insurance and consent to bill them on your child’s behalf. We will verify your insurance coverage, and your co-pay will be determined. IF THE INSURANCE COMPANY THAT YOU DESIGNATE IS INCORRECT, YOU WILL BE RESPONSIBLE FOR PAYMENT OF THE VISIT AND TO SUBMIT THE CHARGES TO THE CORRECT PLAN.

2. We participate with many different insurance plans, so we may not have all the details of your insurance benefits. Some of your questions can be best answered by a representative of your insurance company. It is your responsibility to provide us with all insurance information for the patient, including primary and secondary insurance plans. We will make an effort to assist you in billing any secondary insurance you may have and are contracted with most major state-funded and commercial plans. However, submission to a secondary insurance company is the primary responsibility of the patient.

3. If we are your primary care provider, please make sure our name or phone number appears on your card. If your insurance company has not been informed that we are your primary care provider as of the date of your appointment, you may be asked to reschedule in order to avoid your being financially responsibile for the visit.

4. According to your insurance plan, you are responsible for any and all co-payments, deductibles, and coinsurances. Co-payments are due at time of service.

5. Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 10 business days of your receipt of your bill. Patients with an outstanding balance more than 60 (sixty) days old must make payment arrangements prior to scheduling future appointments.

6. If previous arrangements have not been made with our office, any outstanding account balance over 90 (ninety) days will be forwarded to a collection agency. If forced to turn your account over to a Collection Agency to collect payment on services rendered, we will include all fees charged by the court, attorneys, or collection agency for services.

7. If you participate with a high-deductible health plan, we may require that a copy of the health savings account debit/credit card or a personal credit card remain on file. There are addenda to this financial policy, which are signed separately.

8. Before making an annual physical appointment, check with your insurance company to see whether the visit will be covered as a healthy visit. While many insurance carriers provide payment in full for our services, some do not. Certain services and procedures provided by Little Oak Pediatrics (such as wart treatments, vision screens, etc.) may be your responsibility through your deductible. Some care provided during a well child visit may be deemed as sick care by an insurance company, prompting a copay and separate charge. There is no way for us to know what services and procedures your policy covers until we file the claim and receive a response from your insurance company. It is your responsibility to know what services and procedures are covered under your policy and which services and procedures may be applied to your deductible. Any questions on whether a particular service or procedure will be covered or applied to your deductible should be directed to your insurance carrier prior to your visit to our office; there is no way for us to access this information.

9. Please be on time for your appointments. In the event that you are late, we will do our best to accommodate you. However, there may be certain situations where we will have to reschedule your appointment.

10. We require 24-hour notice for canceling any appointments. After the first missed appointment, you may incur a $15 “No Show” fee for subsequent appointments that are missed without any notice. If you have more than 3 (three) “No Shows,” our office may be forced to discharge you from the practice.

11. If your child has school, camp, or sport forms to be completed, please note that we have a 3-to-5-day turnaround time for forms. If a form is needed sooner than 3 days, there may be a $5 fee.

12. Advanced notice is needed for all non-emergent referrals, typically 3 to 5 business days. It is your responsibility to know if a written referral or authorization is required to see specialist, if the selected specialist participates in your plan, and what services are covered. Remember your primary care provider must approve referrals before being issued.

We want to provide the best possible care for all of our patients. To do that we try to see every person we can at a day and time that is acceptable to them.

We understand that there are times when you must miss an appointment due to emergencies or surprise obligations for work or family. However, when you do not call timely to cancel an appointment, you may be delaying another child from getting much needed care. Conversely, when another patient fails to cancel timely, we may be unable to schedule your child for care.

Your child’s appointment will be considered “Missed”, if:

• A Well-Child / Physical appointment is not cancelled at least 24 week-day hours (Monday through Friday day) in advance or if

• A Sick Appointment is not cancelled at least 1 hour in advance.

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If appointments are “Missed” three times, we may need to end our relationship.

Why: if we do not have your cooperation in providing your child with consistent reliable care, we believe that some other setting or provider may be more suitable for her/him. This is such an important issue that most insurance companies track the child’s care and require us to provide information regarding the child’s health status. As a result, if we end our relationship, we may inform your child’s insurance company of the termination.

Notice of Privacy Practices (HIPAA)