Clinic Policies

Missed Appointment Policy

Please note, when a family does not show up to a visit, or cancels without enough advanced notice, then that appointment spot is left unfilled. This spot would have been used to see other patients. Missing a visit, or canceling without enough advanced notice prevents another family from being seen sooner. From a small business perspective, missing a visit, or canceling without enough advanced notice, is lost revenue, which is important to a small, family-owned business.

Missed Appointment / Late Cancellation / No-Shows: $50:

I agree to pay $50 for a missed appointment that is not canceled at least 24 hours in advance. Cancellations MUST be made over the phone, as cancelling online often leads to delay of our clinic being made aware of the cancellation.
To re-schedule the visit, a credit card must first be put on file with our practice. I agree to have the $50 missed appointment fee charged to the credit card at the time of rescheduling the visit.
I also agree to pay a $50 fee for each subsequent missed appointment that is not canceled at least 24 hours in advance, with the $50 being charged on the day of the missed appointment to the credit card on file.
If a family does not have a credit card available, then the $50 fee to reschedule the visit must be paid in cash in order to schedule an appointment, and an additional $50 must be paid to secure the rescheduled visit. The additional $50 will be refunded at the time of the rescheduled appointment, or applied as a no-show fee if the rescheduled visit is also missed or canceled with less than 24 hours advance notice.
If a new patient misses 2 appointments, regardless of timing of cancellation, then no further appointments will be scheduled.
For families that have not signed this form, we have asked all patients to review our cancellation policy on our website, prior to their visit (communicated verbally and/or via text message and/or email). For a missed appointment that is not canceled at least 24 hours in advance, there is a $50 rescheduling fee to reschedule a visit. In order to reschedule a visit, the family must agree to the above policies, put a credit card on file (or pay in cash, as above).

Online Scheduling: a credit card is required to be put on file in order to schedule a visit using our online scheduling tool. This card will be charged if there is a late cancellation or missed visit, per our missed visit policy.

Please note the date and time of your appointment when made. Appointment reminders are a courtesy, and you may not always receive one.

Consent For Care, Clinic Policies, and Financial Terms and Conditions

Consent for Care: I, patient/parent/authorized representative, give permission for examinations, diagnostic procedures, and medical treatment. Such services will be performed or prescribed by the attending pediatric cardiologist.

Returned Check Fee: $50: I agree that if a check is returned to my account for any reason, I will be responsible for a $50.00 returned check fee in addition to the original fees for services.

Financial Policy: The following is a statement of our Financial Policy, which we require a responsible party to sign prior to any treatment. All patients/parents must complete this form prior to seeing the Pediatric Cardiologist.

We are committed to providing excellent medical care at a fair and reasonable price. Our staff will be happy to discuss any fees or financial issues in advance or at the time of your visit. We will make every effort to work with you to file insurance claims and resolve any outstanding balances in a timely manner.

Insurance: Each insurance policy is individual and it is the member's responsibility to fully understand their in/out network status with this practice, insurance benefits, eligibility date, and what is covered or not covered by your insurance. If the insurance company has not processed and paid the claim within 90 days of submission of the claim, then payment of the account will become the responsibility of the parent/legal guardian. If an insurance company denies payment for an echocardiogram or other testing or services based on a lack of a prior/pre-authorization or the insurance company denying the prior/pre-authorization, the family will be responsible for the cost of the echocardiogram.

- In the event of a separation/divorce, the parent bringing the child for the appointment is responsible for payment of the copay, which is due at the time service is rendered. If you sign this form, you will be held responsible for any amount owed and it will be your responsibility to collect from the divorced/separated spouse.

Demographic Information & Insurance Cards: It is extremely important that we have updated demographic data from both parents so that we will be able to contact you in the future. We also must have a current copy of your insurance card on file at all times. If your insurance changes, it is your responsibility to let us know as soon as possible and to inform us of the effective dates for your new policy. If prior encounters need to be refiled to a different insurance, you must notify us immediately due to timely filing requirements by your insurance, If we do not have your updated insurance information, then your claims may be denied for timely filling by your insurance and those claims would become your financial responsibility.

Network Providers: It is your responsibility to know if your physician is considered "In-network" by your insurance. Please call your insurance to verify. You may contact our Business Office, if you have additional questions regarding network eligibility.

Co-Pays, Co-Insurances & Deductibles: I understand that any co-payments, deductibles and co-insurances are due from me at the time of service. I understand that I am responsible for any balance not covered by my insurance.

You may be contacted by our office at any of your contact numbers listed to attempt to resolve any outstanding balances. In the event that the account is not resolved, I understand that my account may be turned over to a collection agency and my child/children will be terminated as patients of Pediatric Cardiology of Winchester.

Assignment of Benefits/Authorization: As parent or legal guardian, I authorize payment of medical benefits to be made directly to Pediatric Cardiology of Winchester for services rendered. I further agree to be fully responsible for all lawful debts incurred for services provided.

*Accepting New Patients

Clinic Policies