Rose City Pediatrics

Advanced Beneficiary Notice

FINANCIAL RESPONSIBILITY AGREEMENT

Acceptance of Full Financial Personal Responsibility for All Charges

 

I am the legally responsible parent and/or guardian for the minor child noted below.  I understand and agree to pay in full all charges incurred for the provision of health care and health care related services to my minor child at the time the services are provided.

 

Advanced Beneficiary Notice

 

I understand that my insurer may not pay or cover services that are recommended or that my child’s doctor believes are required.  I also understand that the Rose City Pediatrics Medical Group (“Group” or “Office) practices medicine that is consistent with the highest professional, ethical or community standards.  In such cases, I want the items or services that my insurer does not cover or pay for to be provided to my child, and I agree to be wholly responsible for the payment for these services.  I also understand that my child’s physician will discuss the treatment options prior to providing the services to ensure that my child’s health outcome may be maximized at minimal cost.  Notwithstanding the forgoing, I further understand that this may not be practical in all occasions, either because time does not allow it or because my physician cannot reasonably be expected to prospectively know the terms, conditions and limitations of coverage of my child’s health insurance coverage.

 

Parental Right to Notice of Charges for Professional Services

 

I understand that I am entitled to receive a fee schedule that outlines the current charges for the physicians and staff of the Group.  I understand that this schedule will describe the costs of care and alternate payment options.  I understand that the prices are only for the day services are provided, and may change from time to time.  I agree to pay all charges that are the patient’s responsibility and that are generally described in the insurer’s Explanation of Benefits (“EOB”) form

 

EOB 

 

I understand that the insurer’s EOB may provide inaccurate claim reimbursement information that could result in the Group being inadequately compensated for the treatment and care provided by the Group’s health care practitioners.  If that is the case, the Group will notify the patient of the billing error that is described in the insurer’s EOB and charge the patient the correct amount by (i) deducting the amount from the patient’s retainer, (ii) bill the credit card on file with the Group or (iii) invoice the patient for the correct amount.

 

Third Party Billing Agreement

 

I understand that when my child receives care from this Office, a claim is submitted to my insurer or a bill is provided to me for payment if I do not elect coverage by a third party payor (i.e., insurer).  If I elect to request that a third party payor (“insurer”) be billed on my behalf, I will agree to pay all reasonable processing fees, late fees and other administrative fees associated with this choice, consistent with California law.  I understand that these fees are outlined in the Group’s fee schedule list that I have been given.

 

Agreement

 

This Agreement, Retainer Agreement, Credit Card Authorization and Payment Options constitute the sole and entire understanding of the parties with respect to the subject matter contained herein, and supersedes all prior and contemporaneous understandings and agreements, both written and oral, with respect to such subject matter.  This Agreement will remain in force until revoked by me in writing.

 

I understand that revocation may be viewed as voluntary abandonment of the Group and that, upon revocation, professional services and billing privileges may be suspended or terminated.  This Agreement will apply to all siblings and family members.

 

 

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Parent signature                                                                                                              Date

 

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Patient Name                                                               sibling                                      sibling