Office Policies

The following is a list of office policies that you as the responsible party for the “minor” child must be informed. Please read these policies carefully and ask the receptionist any questions you may have. At the end of this written “Office Policies” form you will need to sign, thereby stating you have read the policies, understand the policies, and will adhere to the policies.

1. The adult accompanying the patient is responsible for payment of services provided.
2. Payment is due at the time of service.
3. We accept certain insurance programs. If you belong to one, you must present your insurance card at each visit. If your program includes a deductible, it must be met before we accept your card.
4. If your appointment is on a day we cannot verify your insurance coveragt:you will have to pay for the visit or reschedule your appointment.
5. Co-payments must be paid at the time of service. If the co-payment is not paid at the time of service a late fee may be assessed.
6. Co-payments may not be charged. Your company will be notified if this occurs.
7. We require a photo copy of your driver’s license or Texas identification card be placed in your child’s chart.
8. When a child of divorced parents is treated and the parent bringing the child is not the parent whose managed care insurance covers the child, then the parent must pay the copayment.
9. When both parents are employed and have insurance coverage for the child, the parent with the earlier birthday in the year will supply primary coverage and the other parent will supply secondary coverage in most cases. However, the adult bringing the child for treatment is responsible for payment for that day’s visit.
10. If a residual balance occurs after your insurance company has paid, then you are responsible for that amount and payment is required within 30 days from notification.
11. Work-in appointments for sick children will be worked into the regular appointment schedule. For this reason, there could be a delay of a few minutes to be seen. During peak flu and immunization seasons this delay could be longer.
12. Non-emergency telephone calls made between 11:00 p.m. and 7:00 a.m. will be charged a fee.
13. If you are late for an appointment, you will be worked into the schedule or you may reschedule your appointment.
14. If you are unable to keep a scheduled appointment, please notify the receptionist at least 24 hours in adv nce or in extreme situations, as soon as possible. Otherwise, a $25 “No Call/No Show” fee is assessed per patient for missed appointments without cancellation.
15. The office has made a great effort to provide a pleasant environment in the office for your pleasure while you wait to see the physician. Therefore, in consideration of our patients, please do not eat or drink in the waiting room. We also ask that no one wear hair rollers; revealing clothing, such as “hot pants”, sheer fabric clothing, or revealing necklines; or inappropriate clothing, such as printed words or pictures of an obscene or vulgar nature.

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