Our office would like to welcome you to our family of physicians and healthcare providers. Thank you for choosing us to care for you and your loved ones, we are committed to your healthcare. This Policy and Procedure statement is intended to answer common questions about our practice.
While we hope to maintain a longstanding relationship, we must ensure all patients follow our policies. We require all patients and or parent/guardians to read and sign this statement which will be kept in each patient’s chart. Failure to adhere to these policies can result in dismissal from the practice. Please acknowledge the policy by filling out the form completely.
We require all patients in our practice to have an annual physical regardless of insurance benefits or personal beliefs. We believe an ongoing relationship must be maintained in order to provide you with the best healthcare possible. If you have not had a physical with our practice in the last year, we will not be able to dispense any medical advice, complete forms or refill any medications. We want you to create an ongoing relationship with our providers to best serve your health needs. Once the patient has reached 3 years of age physicals will be scheduled one year from the date of the last physical per office policy. For patients under the age of 3 our well child visit requirements are: newborn, 2 week, 2 month, 4 month, 6 month, 9 month, 12 month, 15 month, 18 month, 24 month and 30 month. If you do not follow the standard of care, in the event of a DCFS case we will be unable to support you. Failure to follow the physical requirements will result in termination from the practice without additional warning.
We make an effort to keep our patients and providers on time. If a patient is 10 or more minutes past their scheduled appointment time, we may have to reschedule the appointment.
If you are coming in as a new complex or difficult diagnosis patient, we require that you leave a credit card on file at the time of making your appointment. We also require your medical records be sent to our office and they must be received 1 week prior to the appointment. Our providers will review these medical records prior to the visit. We will bill your insurance company for reviewing the medical records. You are responsible for any out of pocket expense that may result from the review of the medical records even if the appointment does not take place for any reason. If we have not received your medical records within that time your appointment will need to be rescheduled. If you cancel your appointment, less than 24 hours in advance, or do not show for your appointment you authorize Whole Child Pediatrics to charge the credit card provided a $100 cancellation/no show fee.
Cancellation/No Show Policy
To ensure all patients have access to our medical providers, we have established the following fees for late cancellations and no shows. Office visits cancelled less than 24 hours in advance or on the day of the appointment (regardless of when scheduled and includes if you reschedule the day of your appointment) will be charged a fee based on the appointment type:
• Sick visit appointments (15 minutes) - $25
• Allergy testing, complex appointments or adult physicals (30 minutes) - $50
• These fees are charged to the patient not the insurance company
Ongoing occurrences of no shows may result in termination from the Practice.
It is your responsibility to understand your insurance plan. If your vaccines are not covered by insurance you are responsible for the charges. In addition, if you agree to a vaccination but change your mind after it has been prepared, you will be responsible for the cost of the vaccine, whether it is administered or not. If you choose to not vaccinate, there may be a charge for vaccination counseling that is performed at every well child visit. Please note that we are required, based on our insurance contracts, to document at each visit if your child is underimmunized. Please note, if you require a Religious Exemption Form to be completed there is a $25 fee that is patient responsibility and not billed to insurance.
Divorce Situations/Separation/Unwed/Court Proceedings
In divorce/separation/unwed situations, we require a copy of the custody order, for our office, to provide the office with information as to the status of legal custody, and the specific language critical to determining whether the consent of both parents is required for treatment of the minor. Unless court ordered, you will need to work with the other parent to decide who will be the guarantor on your child’s account and be financially responsible. It will be the guarantor’s responsibility to pay in full and seek reimbursement, if necessary, from the other parent.
It is agreed that, should there be legal proceedings (such as, but not limited to divorce/custody disputes, injuries, lawsuits, etc.) neither you, nor your attorney, nor anyone else acting on your behalf will call on your Provider, or this practice, to testify in court or at any other proceeding, nor will a disclosure of the records be requested unless otherwise agreed upon.
For quality and training purposes all incoming and outgoing calls may be monitored and recorded.
It is known that from time to time the Providers may recommend supplements, homeopathic remedies or other products that are carried at The Natural Pharmacy. The patient is aware they are under no obligation to purchase any recommended products from The Natural Pharmacy. Whole Child Pediatrics strongly recommends if not purchasing products from The Natural Pharmacy that you purchase from a trusted source.
For Whole Child to release medical records from our offices, we must have a completed and signed release form. We charge a $25 medical records fee per person per request. Requests are processed in the order in which they are received, but all requests will be processed within 30 days in accordance with HIPAA requirements and once the fee has been paid. This is office policy and will not be altered based on hospital/insurance carrier policy. Once you request your records, you will no longer be able to receive services from our clinic including appointments, medical advice or prescription refills.
You, or another Provider, may request medical records and transfer out of our Practice at any time. However, if you would like to reestablish care, and you are allowed to return, there will be a $50 return fee per individual. This fee must be paid in advance before any appointments can be scheduled.
Please allow 3-5 business days to fill out any form. A valid ID must be shown for us to release forms, prescriptions etc. If the person picking up the form is not the stated patient, their name must be listed on the HIPAA release form. We fill out school, sports/camp forms, asthma medication school forms and others during your child's office visit free of charge if the request is made at the time of your child’s visit. If a request to complete a form occurs after your child’s visit, a $15 per form fee will apply (IL School Forms, Sports Participation Forms, Camp Physical Forms, Asthma Medication Forms, Asthma Action Plan Forms, Medication in School Forms, School Excuse Notes, or other forms not listed). Religious Exemption Forms are $25 per child regardless of when they are completed.
From time to time, parents need letters written and signed by the staff or the doctor on the practice's letterhead. Generally, these letters are not templates, thus require time to prepare and write. For such letters, there is a charge of $25. We will need at least 2-weeks to complete the letter.
You will be required to provide your driver’s license (or state issued ID) and insurance card, sharing ministry plan card or uniformed service ID card at every visit. You will also be asked to verify the contact information that we have on file. If you have a change of insurance or contact information please notify the office immediately to update the account(s). If you have a co-pay this must be paid at time of service.
Please be advised that you are responsible for taking care of your child during the office visit and cannot leave any child unattended. We will not be held responsible in case of harm to you or your child. Cleanliness prevents the occurrence and spread of infection so shoes must be worn at all times while in the office. If you or your child are actively vomiting please let reception know so they can have you or your child transferred to a room as soon as possible. We have a number of patients who have severe food allergies. We ask that no food be consumed in the office.
After Hours Calls
After hours phone calls are for emergency coordination of care. Any issues related to appointment scheduling, billing, prescription refills and medical issues of a non-urgent nature must be addressed during regular office hours. In case of a life threatening emergency, please go to the nearest emergency room. After hours phone calls that are not for emergency coordination of care will incur a $50 charge, charged directly to the patient.
Termination From The Practice
We reserve the right to discharge any patient/family from the Practice for reasons of nonpayment, non-compliance or ongoing occurrences of no shows/cancellations. If at any point you or a family member become verbally/physically abusive or threatening to our staff/Providers, you will be asked to leave the premises and law enforcement may be called.
We are required by law to maintain the privacy of protected health information and to provide patients with the notice of our legal duties and privacy practices with respect to protected health information. This notice is effective April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have the recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with our office or with the Department of Health & Human Services, Office of Civil Rights, regarding violations of the provisions of this notice or the policies and procedures of our offices. We will not retaliate against you for filing a complaint.
Things to bring with you to every visit:
· Health Insurance Card / Health Sharing Ministry Plan Card
· Driver's License
· Method of payment - for your convenience we accept cash, debit/credit cards and checks.
Foreign Exchange Students/ Out of State Student Insurances/Temporary/Short Term/Ancillary Insurance:
· We do not accept any foreign exchange, out of state student insurance or temporary/short term/ancillary insurance plans.
· We only bill primary major medical insurance.
Payments for Service:
· We accept Visa, MasterCard, AMEX, and Discover, debit cards, money orders, personal checks, and cash. Starter checks and postdated checks are not accepted. We require a valid ID with photo to write checks. If a personal check is returned for any reason, a $30 fee will be added to the original amount. After two returned personal checks, we will not accept further payments by personal check. Co-payments, coinsurance's and/or deductibles are to be paid at time of service.
· Payments need to be sent to the remit to address located on your statement.
· Payment in full is due by the 15th of the following month as noted on the monthly statement you will receive.
· If you are utilizing your banks bill pay system to send us payment please know that it can take anywhere from 7-10 days for that payment to be received.
· For your convenience, you may pay online through our website www.wholechildonline.com.
· We will work with any patient who is in need of payment arrangements. Please call the billing department and they will work with you to set up a mutually feasible payment plan.