Relationship to Patient: ___________________________ _
PARENT INFORMATION
Mother's Name: SS#: ---------------
Address:------------------ Home Phone: ________ _
Cell Phone: _________ _
Employed by: _______________ _ Work Phone: ________ _
Work Address: _______________ _
Father's Name: SS#: ---------------- ------------
Address: Home Phone: ------------------ ---------
Cell Phone: _________ _
Employed by: _______________ _ Work Phone: ________ _
Paula N. Fergusson, MD • Fatema Bukhari, MD • Charmaine Tuck, MSN, FNP-C
46165 Westlake Drive• Suite 210 • Potomac Falls, VA 20165
Phone: (703) 433-1555 Fax: (703) 444-9830
www .kfpediatrics.com
PATIENT FINANCIAL POLICY STATEMENT
The Physicians and staff of KidsFirst Pediatrics are here to serve your needs as our patient. It is our goal to create an experience for our patients that hopefully will limit the amount of stress patients may encounter. Our PATIENT FINANCIAL POLICY is intended to describe our expectations regarding the payment for services we provide. Unless otherwise noted, payment is due at the time of service.
Our staff is prepared to provide patients with any assistance or resources possible in making payment
arrangements for services. We ask that patients recognize their responsibility to understand the services their
insurance covers as well as what documents are required to assure that payment is made. The PATIENT FINANCIAL POLICY details the expectations of our medical group as they relate to patients making
payment for provided services. Patients should acknowledge the following policy requirements: 1. The patient, or their designated gu.;1rantor, is responsible for payment of services.
2. All office charges, co-payments, and applicable deductible amounts are due at the time of service unlessotherwise specified. If we must bill for a co-payment, an extra charge may be added.
3. The provision of an insurance card for payment of services will be accepted, and filed on behalf of the
patient; however, the patient is still responsible for payment if their insurance coverage fails to adequatelyprovide payment in a timely or appropriate manner.
4. Patient account balances are due within 30 days of the receipt of the billing statement unless otherwise
specified.5. If necessary, patient may contact our patient account representatives to make payment arrangements.6. After 90 days, if no arrangements have been made for payment, or if no payments have been received,
collection proceedings will begin.
7. Delinquent accounts may be assigned to a collection agency. All collection costs will be added to youroutstanding balance and will become an additional cost to you. We will not be held responsible for any
collection agency fees.
8. There is a $10.00 fee plus 50 cents per page for the first 50 pages and 25 cents for every additional page tocopy medical records. Completion of all patient requested forms (adoption forms, camp forms, school
forms, sports physical forms) have c1 fee of $10.00 and all patient requested medication forms have a fee of$5.00.
9. We accept Visa and MasterCard. Checks returned for non-sufficient funds will be charged a $30.00 servicefee.
10. The fact that your health plan or policy may not cover a particular service (strep test, flu test, lab work,
immunizations) does not mean they are not important in the care of your child. These costs will be your
responsibility.
11. Saturday visits are considered "after hours" and reserved for sick or emergency visits only. There is anextra fee for this that your insurance may not cover, in this case the patient will be responsible.
12. Your are responsible to keep scheduled appointments and to notify the office 24 hours in advance if youare unable to keep scheduled appointments. The no-show fee is $35.00.
We ask that each patient/guarantor sign this document as part of his or her registration at KidsFirst Pediatrics PLLC in
accordance with the following statement:
"I, _______________ (patient/guarantor), acknowledge that I have received and read this financial policy statement."
Parent/Guarantor Signature Date ------------- ------------
Paula N. Fergusson, MD• Fatema Bukhari, MD• Charmaine Tuck, MSN, FNP-C
46165 Westlake Drive• Suite 210 • Potomac Falls, VA 20165
Phone: (703} 433-1555 Fax: (703} 444-9830
www.kfpediatrics.com
PATIENT RESPONSIBILITY AGREEMENT
*Initial each line after reading*
• I understand that I must provide my insurance card and photo ID for each visit before seeing thedoctor.
---
• I understand that all copayments are due at the time of service. __ _• I understand that if I have an outstanding balance, it must be paid before seeing the doctor
unless other arrangements have been made with the billing department prior to theappointment. ___
• I understand that if my insurance requires a referral, I need to inform my primary care doctor atleast 7-10 business days prior to my specialist appointment (unless it is an emergency).
---
• I understand that if I fail to cancel or reschedule my appointment at least 24 hours in advance, Iwill be charged a $35.00 fee. ___
• I understand that even though the office calls to confirm my appointment, it is ultimately myresponsibility to remember my appointment.
---
• I understand there is a $40.00 fee for any returned checks to the office. ___• I understand that, unless payment arrangements have been made, any outstanding balance not
paid after 3 statement s may be referred to an outside agency for collection. __ _• I understand after-hours phone calls to the on-call physician are subject to a $15.00 fee. __ _
PATIENT CONSENT
I understand that providing proof of my insurance plan does not hold KidsFirst Pediatrics PLLC
responsible for verifying this information. I accept financial responsibility for any lapse in my part in
providing the correct insurance information, and/or understanding my insurance benefits at the time
services are rendered. I understand that it is my responsibility to notify the office of any chances to my
address, phone numbers, insurance (new prefix, ID#, new group, etc.).
I understand the terms of this financial policy may be amended at any time without prior notification to
me, the patient or parent/legal guardian of said patient.
Printed Name of Patient/Parent/Guardian --------------
--------------
Signature of Patient/Parent/Guardian
______________ Date
Paula N. Fergusson, MD • Fatema Bukhari, MD• Charmaine Tuck, MSN, FNP-C
46165 Westlake Drive• Suite 210 • Potomac Falls, VA 20165
Phone: (703) 433-1555 Fax: {703) 444-9830
www.kfpediatrics.com
Receipt of Notice of Privacy Practices
Written Acknowledgement Forms
I, _____________ (name), have received a copy of Kids First Pediatrics PLLC's
Notice of Privacy Practices and agree to the use and disclosure of my individually identifiably health
