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Parent or Legal Guardian's information

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First Parent

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Second Parent

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SIGNATURES by Patient or Legal Guardian

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Privacy Statement

We take your privacy seriously. Your information will NEVER be sold to, or shared with anyone outside of our HIPAA certified clinical team, website and billing departments. I understand that despite the clinic's best efforts, due to the online nature of this form, it is not a completely secure form of communication and my protected health information may be put at risk of breach of data. It is with this knowledge that I complete this form. I do not hold San Fernando Pediatrics & Urgent Care or their employees and representatives responsible for any breach of data. I understand that I have the option to provide these information in person or by fax, which are more secured forms of communication.

Non-Covered Services Waiver

We pride ourselves on providing only the highest quality care for you and your children. We do this by following many of the American Academy of Pediatrics, American Medical Association and other trusted sources for evidenced-based clinical outcome information. However, some insurers rarely keep pace with guidelines, or want to cover services related to meeting these clinical recommendations. As prompt and appropriate treatment for you and your child is of primary importance to us, we ask that you sign a ‘waiver’ giving us permission to perform these screenings, tests and non-covered services. When your treating provider deems certain non-covered services may be appropriate, our medical team will inform you of the cost before they are rendered.

I acknowledge receipt of the non-covered services waiver and have been informed of, and hereby attest that I fully understand my financial responsibility for any balance resulting from non-covered services, or services not covered in-office, by my insurer. I understand and agree that these services will not be billed to my insurance and/or MediCAL. I agree to pay the amount of the charge as billed.  

Financial Policy

San Fernando Pediatrics & Urgent Care participates with most insurance plans. Each insurance policy is different and it is therefore impossible for us to know what your particular benefits may be. Therefore, it is important to contact your insurance company if you have any questions regarding your benefits so that you are aware of your payment obligations at the time of service.

Copayments and Deductibles: Depending on your insurance policy, a co-payment and/or deductible may be required at the time of service. These payments are expected to be made at the time of service. Payment may be made in cash, or by credit or debit card. We also accept Health Savings Account (HSA) cards for payment. Please note that your co-payment is a contractual requirement from the insurance company and cannot be written off by the clinic. If you participate in a High Deductible Health Plan (HDHP) and have not yet paid or met your deductible in full, it is likely that any non-preventive services will require payment at the time those services are rendered. Please ensure that if you are unable to bring your child in by yourself, whomever brings the child, is prepared to make all payments.

Patients Without Insurance Coverage: We are happy to work with families that prefer to pay directly for services. For such patients, a time of service discount is included in the bill that is paid on the day of service. Any procedures or treatment that is provided is in addition to the office visit fee. All payments are due on the day of service.

No-Show & Same-Day Cancelation Fee:Missing an appointment without giving prior notice, deprives other patients of the chance to make an appointment for that time. We require a notice of at least 1 business day for all cancellations. Failure to notify the clinic in a timely manner will result in a no-show fee of $50 per individual patient appointment. Repeated no-shows will result in the family being advised to transfer care out of the practice.

Authorization to Treat and Bill & Assignment of Benefits

I have read, understood and agree with the above financial policies. I consent to be treat by San Fernando Pediatrics & Urgent Care and any provider at this clinic. If I am not the patient, I am authorized to consent to treatment and billing for the patient identified below. I authorize San Fernando Pediatrics & Urgent Care, to bill my medical insurance for the care I receive and to release any information the insurance carrier requires to process this claim/bill. I authorize payment of medical benefits to San Fernando Pediatrics & Urgent Care. I understand that I am responsible for all charges for the treatment I receive. I understand that if I do not provide accurate and complete insurance information, San Fernando Pediatrics and Urgent Care may not receive payment from my carrier and I will be entirely responsible for my bill. Even after my medical insurance pays San Fernando Pediatrics & Urgent Care, I may owe payment for services not covered by my insurance and I agree to pay these promptly and no later than in 30 days. I understand that San Fernando Pediatrics & Urgent Care may send lab specimens to an outside laboratory (QuestDiagnostics, LabCorp, PrimexLabs, or WestPacLabs). I authorize any lab performing services for me to bill my medical insurance for their services. I understand that my medical insurance may not pay for all services provided by the lab and I agree to pay any remaining balance promptly to any outside lab providing services to me. I understand that San Fernando Pediatrics & Urgent Care is not responsible for payment to outside labs for tests provided to me unless I pay for these services directly to San Fernando Pediatrics & Urgent Care on the day of service. To protect my privacy and prevent fraud, I understand that if I cannot provide acceptable photo identification at the time of service, San Fernando Pediatrics & Urgent Care may choose not to bill insurance and may decline to accept credit/debit cards or checks as a form of payment. I understand that if I fail to pay San Fernando Pediatrics & Urgent Care for services provided to me, the balance owed will be sent to collections and I will incur collections fees of 35% in addition to the amount owed for services/treatment rendered. I understand that I may contact San Fernando Pediatrics & Urgent Care to work out payment arrangements that may prevent this additional cost.

All professional services rendered are charged to the patient and are due at the time of service, unless insurance coverage is verified and San Fernando Pediatrics & Urgent Care is a participating provider. Necessary forms will be completed to file for insurance carrier payments.

Assignment of Benefits: I hereby assign all medical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including private insurance and any other health/medical plan, to issue payment check(s) directly to San Fernando Pediatrics & Urgent Care for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information: I hereby authorize San Fernando Pediatrics & Urgent Care to: (1) release any information necessary to insurance carriers regarding myself and/or my dependent's illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing. I have requested medical services from San Fernando Pediatrics & Urgent Care on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges (copay, coinsurance and/or deductible) incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

Credit Card on File

In order to collect your portion of the bill once your insurance company processes the claim, it is our policy to have a valid credit card secured on file with the practice. Your card will only be charged the outstanding amount that your insurance company determines to be ‘patient responsibility’, as spelled out in your Explanation Of Benefits (EOB) in addition to non-covered expenses under your policy. Once your card is charged, a receipt may be sent to you by email or text to your mobile phone upon your request. I understand and agree that all credit card chargebacks (credit card disputes) will incur a $50 administrative fee in addition to late fee and collections fee. Late fee is calculated at 15% per month. Collections fee is calculated at 35% of total amount.

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the law of the state of jurisdiction, and not by a lawsuit or resort to court process except as the law of the state of jurisdiction provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/ her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses. Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well. Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient. Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with the law of the state of jurisdiction. I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy and I acknowledge to have been given enough time to read this agreement and given time to ask questions. By my signature below I attest that I understand and agree with this arbitration agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.