I authorize PEDIATRIC CONNECTIONS or any entity doing business with PEDIATRIC CONNECTIONS, to verify the benefits of our insurance and email us the benefit details.
I authorize PEDIATRIC CONNECTIONS to bill my insurance company directly for the covered portion of charges, and I authorize payment of medical benefits directly to PEDIATRIC CONNECTIONS.
I authorize PEDIATRIC CONNECTIONS to release medical or other information necessary to process this claim.
I understand that the verified estimation of benefits is provided as a courtesy, and does not guarantee coverage. I realize that I am ultimately responsible to know my level of coverage.
PEDIATRIC CONNECTIONS will submit claims to my health insurance company. I am responsible for payment of my deductible, co-insurance or co-payment, and any charges not reimbursed by my insurance carrier.
It is my responsibility to inform PEDIATRIC CONNECTIONS of any and all changes of insurance coverage during the course of treatment. Failure to do so may result in denial of coverage by my insurance company. If my insurance changes, PEDIATRIC CONNECTIONS will bill my new insurance company, but there is no guarantee they will cover the services.
PEDIATRIC CONNECTIONS uses a billing company to process claims and payments. The billing company is of our choice and its employees will have access to protected patient information. This is for the purposes of providing insurance companies with needed information to process claims. Your initials indicate your permission to share protected patient information in order to process payments on your child's behalf.
I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while a patient as PEDIATRIC CONNECTIONS.
I hereby release, discharge and acquit PEDIATRIC CONNECTIONS, it’s agents, representatives, affiliates, employees or assigns of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services.
Please indicate below how I may share protected health information with you. Check all that apply:
All commercial insurance and private pay clients (excludes Medicaid):
To streamline our billing process and to more efficiently collect payments, we are mandating a credit card on file to process all patient related balances. All deductibles, co-insurances, co-payments, missed appointment fees, and all other non-covered services will be auto-charged to the credit card on file. A receipt will be emailed to the email address on file. Upon request, an itemized summary report will be mailed showing how the payments have been applied towards the balance. A $20 processing fee will be applied to all declined credit cards so it will be imperative to keep an updated card on file.
If you have any questions about this policy please contact Julie Frazier, Billing Administrator at (316) 263-0776 or firstname.lastname@example.org
PAYMENT AUTHORIZATION FORM
Required for all non-Medicaid Clients
Please note: If you do NOT have Medicaid, we must have at least 1 credit card on file before we will begin services.
Please contact Julie Frazier, Billing Administrator at (316) 263-0776 to place a credit card on file that may be used to pay remaining balances or copays. Services will not begin until an authorized payment is on file.
I agree to the Payment Policy/Assignment of Benefits/Authorization to Release Medical Information.
By signing, I agree to have Medisource Healthcare Solutions bill my insurance and/or process my credit card after each visit on behalf of Pediatric Connections OT (when applicable for non-Medicaid clients). Information.
Thank you for choosing PEDIATRIC CONNECTIONS for your child’s therapy services.