Insurance and Financial agreement

Our practice does not participate directly with insurance benefits. We would obtain payment at the time of service and as a courtesy we would be happy to submit your child’s claim to your insurance provider so that reimbursement be made directly to you. Please feel free to contact our office if you have any questions.

Late Cancellation Agreement

A great deal of planning is done for your child’s appointment. Changes and cancellations to our schedule without adequate notice are very disruptive to our office, and to other patients waiting for appointments. For this reason, we ask that any changes to your appointments be made AT LEAST 48 HOURS in advance and 72 HOURS if appointment is on a Monday or Tuesday. If this policy is not followed a $100 fee per appointment may be charged to your account, to be paid prior to rescheduling.

Privacy Practices Acknowledgement/HIPPA

The most significant variable that has motivated the Federal government to legally enforce the importance of the privacy of health information is the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of you and your families’ health information.  This has challenged us to review not only how your child’s health information is used within our computers, but also with the Internet, phone, faxs, copy machines, and digital charts.  This has been an important exercise for us because it has disciplined us to put in writing the policies and procedures we use to ensure the protection of your child’s health information everywhere it is used.  We want you to know about these policies and procedures which we developed to make sure your child’s health information will not be shared with anyone who does not require it.  Our office is subject to State and Federal law regarding the confidentiality of your health information and in keeping with these laws we want you to understand our procedures and your rights as our valuable patient. 

  We will use and communicate your child’s Health Information only for the purpose of providing treatment, obtaining payment and conducting health care operations.  Your child’s health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

You may visit the U.S. Department of Health & Human Services website for full details on the HIPPA Act.