FINANCIAL POLICY:
Payment for all services is the responsibility of the parent or guardian who presents to the office with the patient and is due and payable at the time services are rendered.
When health insurance coverage is with a company for which Pediatric Practices of Northeastern PA
(PPNP) is a participating provider, PPNP will submit a claim to the insurance carrier. If this claim is not paid within a timely manner (60 days) by the insurance company, then it becomes the responsibility of the parent or guardian. If the health insurance coverage is with a company for which PPNP does NOT participate the parent or guardian is responsible for payment at time of service unless prior arrangements have been made with PPNP's billing department. Upon the request of the parent or guardian to PPNP's billing department, they will complete a form so that the parent or guardian may receive reimbursement for these services. Insurance contracts and coverage is between the subscriber and their insurance company. To use insurance benefits to cover any ordered tests, procedures or visits to specialists it is the responsibility of the parent or guardian to contact the subscriber’s insurance company to verify benefits and participating facilities and specialists. The parent or guardian is responsible for requesting any necessary referrals prior to seeing any specialists, and prior to having any tests or procedures performed. When possible these requests should be made 5 days prior to the appointment date with the specialist. It is up to the discretion of a PPNP Physician whether or not to issue a referral requested after the appointment or procedure date. Any denial of payment for ordered tests from an insurance company is between the subscriber and their insurance company, realizing referrals are not a guarantee of insurance benefits or payment.

The parent or guardian is responsible for all co-payments and non-covered services at the time of service unless prior arrangements have been made with PPNP's billing department. All co-payments are due at the time of service when checking in the patient. Any co-insurance, deductibles or rejected claims should be paid to PPNP within 30 days of receipt of a bill from PPNP.
For your convenience we accept Cash, Check, MasterCard or Visa.
(Any checks returned unpaid by your financial institution will be subject to a fee of $20.)
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If you wish to have us submit any outstanding balance to your credit card, please complete the following and mail it to our Honesdale office, 1837 Fair Ave, Honesdale PA 18431, attention Billing Department:

I hereby grant authorization to PPNP the use of my credit card for the unpaid balance of $ ____________.

I understand this authorization is for this transaction only and that under no circumstances will the card be used again without my written or verbal authorization.

My credit card information is as follows:

Credit Card No. _______________________________________________Expiration Date: _______/__________

MasterCard/Visa
(circle one)

Cardholder’s name as it appears on Credit Card: ____________________________________

Authorized Signature: ________________________________________________

Date: __________________

Patient Name: ______________________________________________________

Daytime Telephone Number: (_________) - ____________________________