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Financial Policy

3501 Soncy Road, Suite 102
Amarillo, Texas 79119
Tel: 806-353-7900
Fax 806-353-8321
tlcofamarillo.com
Where Compassion, Caring and Dedication Come First

Financial Policy

Financial Policy

"Where Compassion, Caring and Dedication Come First"

Insurance

Insurance is a contract between you and your insurance company. As a courtesy to our patients we have enrolled in many insurance companies. In doing this we are agreeing to file your insurance claims and take the contracted rates from your insurance company, however, we do not take responsibility for items that are not covered by your individual plan. We recommend that you always question the insurance regarding your benefits and do not assume that everything done in the physician’s office is covered. It is also the patient’s responsibility to make sure that we are considered in network providers under your individual plan. TLC Pediatrics of Amarillo will NOT file any claims for patients without an insurance card. You can request your insurance company to fax you with documentation of insurance coverage that includes all billing information. You will need to provide this information every time, as we will not be responsible for any denied claims due to filing deadlines if information was not given at the time of service. If your insurance company requires a referral or pre-authorization, you are responsible for obtaining it.

Labs

(PPL). If your laboratory designated by your insurance company is anything other than Preferred Pathology Laboratories you will need to find which lab is the closest for you to have your lab work done there. Failure to do so can result in a heavy expense to you.

I understand that it is my responsibility to confirm with my insurance company that the physician is currently under contract with my plan or be willing to be seen at “out of network” benefits. Any questions about medical, well baby/preventive care, labs/x-rays and immunization coverage should be directed to my insurance carrier prior to my visits. I agree to be responsible for all copays, deductibles and non-covered services determined by my insurance plan.
I understand that it is my responsibility to confirm with my insurance company that the physician is currently under contract with my plan or be willing to be seen at “out of network” benefits. Any questions about medical, well baby/preventive care, labs/x-rays and immunization coverage should be directed to my insurance carrier prior to my visits. I agree to be responsible for all copays, deductibles and non-covered services determined by my insurance plan.
If I do not have proof of insurance coverage at the time services are rendered, I understand that payment is due at the time of service.

Monthly Statement

If you have a balance on your account, we will send you a monthly statement. It will only show charges that are owed as of that date. Your statement is expected to be paid in full within 30 days after receipt of the statement date, unless other arrangements have been approved in writing. If payment is not received within 30 days it is considered past due. We do reserve the right to dismiss your family from the office if your account cannot be maintained in a fair equitable manner.

Required Payments

Any co-payments, co-insurance, or deductible amounts required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these.

I will promptly pay all amounts that have been determined my responsibility by my insurance carrier upon receipt of my statement. I understand that my health insurance contract is between my insurance company and myself. If my insurance does not pay for the services rendered by the TLC Pediatric of Amarillo or Dr. Maaytah within 45 days, the practice may look to me for payment. The TLC Pediatric of Amarillo or Dr. Maaytah agrees to refund any overpayment that I have made on my account in the event that my insurance eventually pays. Any balance remaining after my health insurance pays, denies or deems non-covered under my plan will be my responsibility. If I have not paid my bill or have not arranged for a payment plan, the practice may ask for the assistance of an outside collection agency. If my account is turned over to a collection agency, I will be dismissed from the practice. The practice will try to work with me to avoid this.

Past Due Accounts

If your balance becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs, which are incurred. If we have to refer the collection balance to a lawyer, you agree to pay all lawyers’ fees, which we incur, plus all court costs. In case of suit, you agree the venue shall be in Randall or Potter Counties, Amarillo, Texas.

Your account will be charged $23 for NSF/Returned checks. Patient due balances of 60 days or more (unless previous financial arrangements have been made) may be charged $10. A non-reversible service fee of 40% may be assessed on your balance if your account is turned to collections.
In order to provide you with the highest quality service while keeping our billing costs low, we offer paperless billing through EASY-PAY. We simply maintain your credit, debit, or check card number on file to satisfy all co-pays, deductibles,

Returned Checks

There is a fee (currently $30) for any checks returned by the bank. If we received more than one returned check on an account you will be required to pay with a credit card, money order or cash. We reserve the right to submit your information to the legal authorities, as this is a crime in the state of Texas.

Separated/divorced Families

After a divorce or separation, the parent authorizing treatment for the child will be the parent responsible for those subsequent charges, including copay, deductible or coinsurance required at the time of service. It will also be that parent’s responsibility to provide us with any insurance information that we may require in order to file any claims. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Waiver of Confidentiality

You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if you’re past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

ransferring of Records

If you want to have copies of your records transferred to another doctor, organization, or for your own personal files, then you authorize all relevant information, you will need to request in writing, and pay a reasonable fee (currently $30) to TLC Pediatrics of Amarillo. If you are requesting your records to be transferred from another doctor to us, you authorize us to receive all relevant information. A copy of your shot record may be obtained in our office. There is no charge for the first copy, but each additional copy, there will be a $5 fee assessed every time requested. If you need a doctor to sign or fill out a form there is a $5 fee assessed with every form you send in.


Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect. I hereby state that I have read and understand the Financial Policy given to me by TLC Pediatrics of Amarillo, P.A.

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