I have completed the Patient Registration and certify the information to be true and accurate to the best of my knowledge at the time of completion. I consent to having a phone call or text from Stepping Stone Pediatrics for verification of information.
STATEMENT OF FINANCIAL POLICIES
I have received a copy of and read the Statement of Financial Policies in effect as of this date and agree to abide by its provisions.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Stepping Stone Pediatrics to release any and all information that in their sole judgment is felt necessary for medical care or for any portion of the processing of a claim for medical services rendered.
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize direct payment of medical and surgical benefits to Stepping Stone Pediatrics for medical services rendered by any of the above.
RECEIPT OF NOTICE OF PRIVACY RIGHTS
I acknowledge that the Notice of Privacy Practices for Stepping Stone Pediatrics was made available for me to read and its provisions apply to all members of my family who seek medical care with Stepping Stone Pediatrics.
ACKNOWLEDGMENT AND CONSENT OF IMMUNIZATION POLICY
I acknowledge that the Immunization Policy for Stepping Stone Pediatrics was made available for me to read and I will abide by its provisions if I wish for my child(ren) to remain patient(s) at Stepping Stone Pediatrics. I consent to have all immunizations uploaded to the Washington State Immunization Registry
CONSENT FOR TREATMENT
I acknowledge and give my permission to receive treatment at Stepping Stone Pediatrics for medical treatments, including but not limited to vaccines, general health services and minor procedures.
I consent to medication authoriztion history pulled for seeking medical care with Stepping Stone Pediatrics.
STATEMENT OF FINANCIAL POLICIES
Since Stepping Stone Pediatrics desires 1) to focus their resources on caring for children as much as possible, 2) to honor patient privacy and confidentiality, 3) to be paid in a reasonable period of time for services rendered, and 4) to acknowledge how special financial circumstances will be handled, I acknowledge that I have read, understand and agree to all of the following financial policies:
1) I agree to provide my child’s current insurance card(s) at every visit. A copy will be kept on record by Stepping Stone Pediatrics.
2) I agree to provide my current driver’s license or other acceptable photo ID upon request. A copy will be kept on record by Stepping Stone Pediatrics.
3) I agree to provide a current, valid credit or debit card (VISA or MasterCard), a copy of which or information thereon will be stored by Stepping Stone Pediatrics in a secure manner as determined solely by Stepping Stone Pediatrics. I agree to allow Stepping Stone Pediatrics to use my credit or debit card solely to pay for any outstanding balance that is deemed my responsibility by the financial policies detailed below. Stepping Stone Pediatrics will provide me with a receipt of payment and a record of services provided for each such transaction if I so request. If the credit or debit card information on record is invalid, I will be notified and agree to provide valid credit or debit card information within 5 business days. If I do not have a valid credit or debit card, I agree to make alternative payment arrangements, in writing, with Stepping Stone Pediatrics.
4) I understand that the parent or guardian of my child that requests treatment is responsible for payment for services rendered, regardless of who accompanies the child to the office.
5) I understand that full payment for services rendered is expected at the time of service. I agree that the full charges for any or all services rendered may be applied to my credit or debit card on file in accordance with #3 above, if Stepping Stone Pediatrics has reasonable evidence that my insurance will not cover the services provided,.
6) In accordance with my health insurance contract, I agree to pay any co-pay at the time of service. If I do not pay my co-pay at the time of service for any reason, I agree that the co-pay may be applied to my credit or debit card on file in accordance with #3 above. Any co-pay that is not paid at the time of service will incur a $10 service charge.
7) I agree to pay a $75 no-show/late cancellation service charge if, regardless of cause, either a) I do not show for an appointment, or b) I do not call Stepping Stone Pediatrics at least 2 hours prior to the appointment time to cancel a visit, or C) I do not notify the office 2 hours or more prior to the appointment time to cancel a visit. If I arrive more than 15 minutes late for my appointment time, I must reschedule the appointment time and will be charged the no show fee. I agree that this service charge may be applied to my credit or debit card on file, in accordance with #3 above.
8) I understand that, in the event of financial hardship, I may be able to make alternative payment arrangements with the office manager.
9) If I have a balance that is outstanding for 45 days or longer and I have not made an alternative payment arrangement in writing with Stepping Stone Pediatrics, I agree that the balance in full may be applied to my credit or debit card on file in accordance with #3 above, if Stepping Stone Pediatrics has reasonable evidence that my insurance will not cover the services provided.
10) I understand that if, for any reason, that I have a balance outstanding for 90 days or longer, my account may be turned over to an outside collection agency. If my account is turned over to a collection agency, I understand that I will be financially responsible for any charge that the collection agency requires in addition to my outstanding balance.
11) If I have made an alternative payment arrangement and I do not abide by its terms, I understand that my account may be turned over to an outside collection agency.
12) I agree to pay a service charge of $35 for each check returned for non-sufficient funds.
13) I understand that in certain instances, at the sole discretion of Stepping Stone Pediatrics, I may be required to pay cash for services before the services are rendered.