Payment or Assignment for payment for all services rendered to the patient are the responsibility of the patient and /or responsible party. A responsible party is defined as the financial guarantor (father, mother) or an insurance company or both. Unless arrangements have been made in advance, if the patient/ responsible party does not have insurance or Derry Pediatrics does not contract with the insurance company, full payment for all services is required at the time that services are rendered.
Non-covered Services Policy
It is possible that some services you received at Derry Pediatrics may not be covered by your particular insurance policy. It is understood that the patient/parent is responsible for the payment of any non-covered provided by Derry Pediatrics.
If the patient/responsible party’s insurance plan calls for a co-payment for office visits, payment of this amount is due at the time services are rendered.
Notification of Change of Insurance: It is the responsibility of the patient/ responsible party to notify Derry Pediatrics immediately of any change in insurance coverage.
No Show Policy:
A no show is someone who misses an appointment without cancelling it with 24 hours advanced notice. No shows inconvenience those indivduals who need access to medical care in a timely manner. A failure to present at the time of a scheduled appointment will be recorded in the patient's chart as a no show. The first time there is a no show there will be no charge to the patient. Any additional no shows will result in a fee of $50 billed to the patient's account.
Medical Records Release Authorization: Derry Pediatrics is hereby authorized to furnish any and all information concerning the patient’s treatment at
Derry Pediatrics to the patient/responsible party’s insurance company if requested.