Prescriptions and
Refill of Medication
| Call your pharmacy if you need a medication
refilled. When appropriate, we can authorize refills through your pharmacy |
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Forms
Please allow us 5 working days for school forms,
camp forms, WIC papers, etc.
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Consent For
Treatment
| If someone other than the legal guardian brings
a child in for a visit, please send a signed note stating that he or she
has permission to
act on your behalf. |
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| Financial
Policies |
The following information explains
our policies and procedures regarding your health insurance and payment
for services rendered in our offices. We wish to remind you that you are
personally responsible for your bill at our offices. It is your
responsibility to know your insurance company’s benefits and coverage
regarding all aspects of medical care, including well child care, mental
health and covered diagnoses.
As a courtesy, we are happy to assist patients who are covered by health
insurance to obtain the maximum benefits provided by their policies;
however, your health insurance is an agreement between you and your
insurance company and it does not affect your financial obligation to
this office. Insurance companies have developed a wide variety of
methods for reimbursement. We are unable to influence what percentage of
your bill your insurance company will pay. Each insurance plan varies in
terms of coverage and the age of the patient can also affect your
insurance coverage. We do not contract with every insurance plan and it
is your responsibility to know if we are participating providers in your
insurance plan before we provide services. As a courtesy to you we will
bill your insurance company, however, in the event they do not pay
claims, you are financially responsible for payment. In order to receive
proper reimbursement, we ask that you provide us with a copy of your
insurance card at each visit. All co-payments must be made at the time
of service.
If you have a newborn baby, the baby must be enrolled with your
insurance immediately. Many insurance companies only allow 30 days for
enrolling a new baby. Payment is expected at the time of service if the
baby is not on the insurance plan.
If you are covered by Medi-Cal we ask that you present your Medi-Cal
card at each visit. If your Medi-Cal is not eligible on the date of
service you will be responsible to pay for any services rendered that
day.
All accounts are subject to filling fees as described below:
 | Co-payment Fee: If you do not pay your co-payment
at the time of service, a $5.00 charge will be added to your account.
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| Statement Billing Fee: If we must send you more
than one billing statement, all subsequent statements will be subject
to a $2.00 statement fee. |
All accounts must be paid promptly. We will establish
payment arrangements with you as necessary however, we ask that all
bills be paid in full within a reasonable period of time. We will not
carry balances past 90 days. All accounts past 90 days with no payment
will be sent to an outside collection company. In this case we will no
longer schedule any appointments for any child in the family until
payment in full has been made and you are reinstated in the practice.
Our billing staff is happy to assist you with any questions you may have
in regard to your insurance company and your account status. We look
forward to being part of your child’s excellent health and will do all
we can to ensure a pleasant experience here at Eureka Pediatrics.
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Thank you for choosing Eureka Pediatrics to care for
your child
We accept Visa, MasterCard,
personal checks or cash. We will also bill your insurance for you.
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