Welcome to Prospect Pediatrics PA

At Prospect Pediatrics, we provide excellent health care for our patients from infancy through age 21years, in a child friendly relaxed atmosphere designed to make children and family members feel at home and safe. There is continuity of care of your child - the same doctor sees your child each visit.

MISSION STATEMENT:
At Prospect Pediatrics, Our goal is to provide an exceptional quality, comprehensive healthcare for our patients in a compassionate and respectful manner. We pledge to take care of the whole child in the context of his/her family, school and community in the highest ethical and professional level. We take that commitment serious . We feel privileged to be part of your child's life.

-At prospect Pediatrics, we listen while you talk
-Every question that you care about is important to us.
-We provide personalized care
-We simply care.

Prospect Pediatrics PA Financial Policy

Patient Name
Patient Date of Birth:
ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE WE DO NOT BILL SECONDARY INSURANCE COMPANIES


Prospect Pediatrics PA is committed to providing you with the best possible care and will be pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important for our professional relationship. Please ask if you have any questions regarding our fees, financial policy or your responsibility. We are doing everything possible to hold down the cost of medical care. You can help a great deal by eliminating the need for us to bill you . The following is a summary of our payment policy.

It is your responsibility to have your most current insurance details with you. You will be asked for your card and applicable co-payments. If your insurance has changed, please obtain the expiration date of your old policy and the effective date of the new coverage, prior to your appointment or visit to the office. If this information is not provided or your insurance is
inactive on the day of service, you will be expected to pay before being seen.

Prospect pediatrics PA accepts cash, personal check, VISA, MasterCard. There is a service charge for returned checks. Patients with an outstanding balance 30 days overdue must make arrangements for payments prior to scheduling appointments or Prospect Pediatrics PA will decline to see the patient.The outstanding balance must be paid within 30 days of receiving statement from Prospect Pediatrics. Prospect Pediatrics PA will decline to see patients with outstanding balances.

INSURANCES

If we have not received payment from your insurance company within 45 days of the date of service,
you will be expected to pay the balance in full. You are responsible for all charges.

COMMERCIAL INSURANCE

We bill participating insurance companies as a courtesy to you. If you are covered by a commercial
insurance carrier that we accept, we will file a claim to your carrier. You must pay any Co-pay, Coinsurance or any deductible at the time service is rendered. If you are a member of any other insurance carrier that we do not accept, you are expected to pay in full at the time service is rendered, and we will provide you with the necessary forms to file a claim with your insurance for reimbursement.

The practice will not receive payment or other remuneration from a third party in exchange
for using or disclosing the PHI.I do not have to sign this authorization in order to receive treatment from Prospect Pediatrics PA. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization,it may be subject to redisclosure by the recipient and may no longer be rotected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written evocation must be submitted to the Privacy Officer at: 163 Belleville Avenue Belleville, NJ 07109

MEDICAID

We bill participating insurance companies as a courtesy to you. We accept Medicaid assignments. Prospect Pediatrics PA does adhere to the New Jersey Medicaid Agreement and Title 42 code of the federal regulation 447.20 and Civil Rights Act of 1964.

SELF PAY

Full payment is due at the time service is rendered. We accept cash, credit cards and debit cards. We try to make our fees reasonable and affordable if you are without insurance at the time of your visit. If you become eligible for insurance coverage after you have already paid for an appointment we will not be able to file your insurance. However, we will be happy to provide you with the necessary forms to file a claim with your insurance for reimbursement.

REFUNDS

Overpayments will be refunded upon written request to the responsible party within 30 days.

WALK IN PATIENTS

if you are not a patient of Prospect Pediatrics PAand want to be seen, e.g. vacationer or out of town guest, you must pay in full for the visit. However, you will be given at the time of service receipt to submit a claim to your insurance company.

MISSED APPOINTMENTS / LATE CANCELLATIONS

Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed or late - to-cancel appointments. Excessive abuse of scheduled appointments may result in discharge from the practice .


MORE THEN 3 NO SHOWS FOR PHYSICAL APPOINTMENTS WILL RESULT IN TERMINATION FROM


Prospect Pediatrics PA.Prospect Pediatrics PA reserves the right to terminate patients who do not follow medical Advice given by doctor and do not show up for follow up appointments.

AGREEMENT

In consideration of the services rendered to me by my physician, I agree to pay all charges incurred as a result of such services. If all or part of my charges are payable by a third party reimburse, I understand that it is my responsibility to contact such third party payer and to arrange for payment. I agree that should the amount for insurance benefit be insufficient to cover the expenses, I will be responsible for payment of the difference. I will be responsible for the entire amount due (excluding disallowed amounts per a managed care contract) for services rendered if the expense is not covered under my policy. I understand that Prospect Pediatrics PA will not become involved in disputes between me and my insurance company regarding deductibles, co-payments, covered charges and/or usual and customary charges other than to supply factual information as necessary.


All fees are due and payable upon billing. The undersigned will pay all costs and expenses including collection fees and attorney fees incurred or paid by Prospect Pediatrics PA in the collection of this obligation by suit or otherwise.


This agreement shall remain in effect until revoked by me in writing. I also permit Prospect Pediatr ics PA to use photocopies of these agreements in place of the originals on file at Prospect Pediatrics PA. Please let us know if you have any questions or concerns.


 I have read and understand Prospect Pediatrics PA Privacy and Financial Policy


Signature of Responsible Party/Guarantor)
Date:

Consent for Treatment

I here by consent to medical treatment, including vaccinations and necessary procedures at Prospect Pediatrics PA, by its Doctor, Nurse Practitioner and other Staff.

Signature of Responsible Party/ Guarantor
Date

Address
163 Belleville Avenue Belleville, NJ 07109

Telephone
973-302-4644

Fax
973.528.2242