The goal of our administrative staff is to make sure that your claims are handled properly and that you have a complete understanding of your out-of-pocket medical expenses. Please look through the policy information below, and do not hesitate to call us if you have any questions. Again, Long Pond Pediatrics does not quote insurance benefits, but asks that you refer to your insurance carrier to understand the benefits/limitations of your policy. For your convenience, payments to Long Pond Pediatrics can be made by cash, check, Visa or Master Card, and can be paid in person, by mail or telephone. Billing office phone # is 585-225-0950 x106.
We require that parents:
Present your insurance card at each visit or when requested.
Pay all copayment and/or deductible amounts (allowed by insurance) at the time of service.
Contact us with any changes of insurance information.
Contact us if having difficulty meeting financial obligations. We would be happy to discuss our payment plan options with you.
Sign a financial release, which includes the following:
- I understand that all copayments and/or deductibles must be paid at the time of service. If not paid at the time of the visit, a $25 billing fee will be charged. The billing fee will be waived if payment is made no later than 11:00 am the following business day.
- I understand that well child exams sometimes turn into an extensive exam or treatment of an illness or injury. When this occurs, the physician may bill my insurance for additional services. A list of examples of these extended services is posted in each exam room. I may opt for well services only, and return for a separate visit to address any additional issues not normally covered during a well visit.
- I understand that a minimum 24 hour notice is required should I need to cancel a well visit or consultation appointment. Failure to provide adequate notice will result in a $50 fee.
- I understand that once an acute visit is scheduled, any cancellation or rescheduling of the visit must be made at least 2 hours prior to the scheduled appointment. If the appointment is cancelled with less than a 2 hour notice, a $25 fee will be assessed. Same day reschedules are limited to 1 per day.
- I understand that if I do not keep an appointment and have not called to cancel, I will be responsible for a $75 "no-show" fee.
- School, daycare or camp forms will be completed within 3 business days. Should I need forms sooner, I understand a $10 service charge will be collected prior to completing the forms.
- In the event a check is returned for insufficient funds, a service charge of $30 plus bank fees will be added to my account.
- I take responsibility for payment of any medical fees not covered by insurance.
- If my child requires lab work that is sent to an outside agency, I understand that I will be billed separately by that agency.
- Patients referred to collection agency for non-payment of services may be dismissed from Long Pond Pediatrics.
*An important message to parents in a custodial, non-custodial or shared parent arrangement*
As is common practice in pediatric offices, out-of-pocket expenses will be collected at the time of service from the parent or guardian who accompanies the child to their visit, regardless of any other financial/legal arrangements dictating who will pay. Bills for any outstanding claims will be sent to the address where the child resides.
Compliance with court ordered arrangements would take place between the involved parties. LPPG does not enter into those arrangements. Any additional issues regarding financial responsibility should be addressed through Family Court Services.