Patient Information Financial Policy: Agreement for Payment Listing Park Place Pediatrics as Primary Care Provider (PCP):  I understand that if Park Place Pediatrics is not listed as my/my child’s PCP that I am responsible to notify my insurance company to change to Park Place Pediatrics as my child’s PCP.  Failure to do so within the time frame required by my insurance company will make me responsible for the services rendered during any visits to Park Place Pediatrics.  Co-Payment is due at the time of the office visit.  Failure to pay co-payment the same day service is provided will result in an administrative fee (currently $10).  Monthly Statements will reflect the amount I owe to Park Place Pediatrics.  Unpaid balances will have a finance charge (currently $5 per month) when they exceed 30 days from the first time patient/parent is sent a bill. No Show/Late Cancellation Charges:  Park Place Pediatrics cannot bill the insurance for these charges, but are permitted by insurance companies to bill for them.  We kindly ask for 24 hours’ notice if you are unable to come to an appointment previously made.   Notifying us 24 hours in advance allows an appointment to be offered to others.  Failure to show up for an appointment without notification is subject to a No Show charge (currently $25 per missed appointment, multiple children from the same family with missed appointments will have a fee of $25 applied to EACH child).  I understand missing multiple appointments and/or failure to pay no show fees without argument will result in being asked to transfer records to another doctor and I am still responsible for the balance owed.    Past Due Accounts:  Accounts that are past due greater than 60 days are subject to being referred to a collection agency.  Park Place Pediatrics will make every effort to inform me of this action.  It is my responsibility to inform Park Place Pediatrics of any change in insurance, address, phone numbers or other information important to medical payments.  Failure to notify Park Place Pediatrics of changes in address or insurance information; does not relieve my responsibility of any charges incurred that are not received by me due to wrong information that I have not updated with Park Place Pediatrics.  Once accounts are turned over to collections, I understand that I will be responsible for late fees, and any collection costs incurred.  If the account is turned over for legal action, I agree to pay all lawyers’ fees and court costs incurred by Park Place Pediatrics as a result of such action. Divorce:  In the case of divorce or separation, the parent who brings the child to the appointment is responsible for making all payments and then collecting from the other parent at their own discretion. Returned Checks:  There is a fee (currently Park Place Pediatrics is charged $30) that will be passed on to me for any checks returned by the bank for insufficient funds.   Transferring of Records:  I will need come into the office and sign a record release form, and pay a reasonable fee (currently $0.75 per page or $15 per family) if I want to have copies of my child’s records sent to me, another doctor or organization.   Waiver of Confidentiality:  I understand that if this account is submitted to an attorney or collection agency, if Park Place Pediatrics has to litigate in court, or if my past due status is reported to a credit reporting agency, the fact that I received treatment at your office may become a matter of public record.  Fees:  I understand that Park Place Pediatrics may reasonably adjust the above fees, from time to time based on fees incurred by Park Place Pediatrics, and that these fees are re-assessed on an annual basis. Office Policies: • We expect our patients/parents/guardians to treat everyone in this office with kindness & respect • Park Place Pediatrics sees patients by appointment only • Patients with balances will be asked to pay in full before scheduling their annual physical exams • Patients/Parents/Guardians are responsible for being familiar with their own insurance policy, IE: Co-pays, deductibles & co-insurance. • Children should not be left unattended by a parent or guardian in the office If you have any questions or comments regarding these policies you may contact:   701 Union Street Schenectady, NY 12305 (518) 374-3511 Consent to treat a minor Parents can give permission for their children to come in without an adult. Acceptable ages. (15,16 & 17 years of age) However, we cannot administer vaccines without a parent or guardian present in the office. Fidelis Doctor Assignment For ALL FIDELIS patients (New and Established)!!!!! Patients/parents must sign a PCP change form. Fidelis auto-assigns Dr's at random to patients when they sign up, and everytime their insurance renews, so we must have a signed PCP form on file to recieve payment. Patient Registration & HIPAA Agreement Completed forms can be faxed or mailed to the office. Fax: (518) 374-3512 Mail to: Park Place Pediatrics c/o Danielle Degener 701 Union Street Schenectady, NY 12305 Patient Proxy This form is for Parents to give permission to babysitters, daycare, grandparents or anyone that is NOT a legal guardian to bring their children (under 18 yrs old) in for their appointments. Patient Record Release (To or From our office) If Patient is 18 years or older, form MUST be completed by the patient. Motor Vehicle Accident Assignment of Benefits FOR ESTABLISHED PATIENTS ONLY In the case of a Motor Vehicle Accident, an AOB must be completed in the office or online. Financial Policy HIPAA (The Health Insurance Portability and Accountability Act) For all Patients, Dr. Hadi Koohsari is the elected Privacy Office for Park Place Pediatrics. If you have any questions regarding your right to privacy, please call the office during regular business hours.