Financial Agreement between Guarantor and Potomac Pediatrics
In return for services provided by Potomac Pediatrics, we expect payment or satisfactory financial arrangements, at the time the service is rendered. Our physicians are participating providers with a large number of health insurance plans. We recommend that you verify our participation with your particular plan as financial responsibility ultimately falls to the Guarantor of each account.

Your insurance policy is a contract between you and your insurance carrier. Thus, it is your responsibility to understand and know the provisions of payment for services rendered at Potomac Pediatrics. Please know any co-payment amount and be prepared to make payment at the time of service.

Financial Responsibility
The Guarantor for the child’s policy is responsible for all co-payment, co-insurance and deductible amounts. Additionally, the guarantor is responsible for all charges and supplies that are not covered by the insurer. Potomac Pediatrics does not bill the Non-covered Service Fee to insurance. Therefore, the guarantor is responsible for payment of this fee, in full, at the beginning of each calendar year (see “Non Covered Service Agreement” under Provided Services for more information).

Payment will be collected at the time of service for any known account balance in addition to any co-payment amount. Acceptable forms of payment include personal checks, cash, or credit card. Return checks are subject to the return check rate of $25: The account will be debited for this amount on top of the original amount of the transaction. After one returned checks, we will no longer accept personal checks on your account.

Copayments, Deductibles and Coinsurance
Copayments, deductibles and coinsurance amounts are contractual arrangements between a Guarantor their insurance plan, and between Potomac Pediatrics and our insurance plans. As these are contractual arrangements, Potomac Pediatrics cannot waive copayments, coinsurance or deductibles for any patient. Copay’s are due at the time of service and will not be billed to you. If you have a deductible, then a deductible deposit of $100 will be due at the time of service.

Our office will make every attempt to verify your insurance benefits and remaining deductible amounts due on your policy. Occasionally your insurance plan may not provide us with the most up-to-date deductible information. However, we must collect any deductible deposit, copay, or coinsurance due based on the current information that has been provided to our office.

Proof of Insurance
Patients should alert front desk staff of any insurance changes prior to being seen. Adequate proof of insurance is required at all visits; be prepared to show a current insurance card. If adequate proof of insurance is not established prior to the appointment, you will be financially responsible for the entire visit at the time services are rendered. Should you wish to submit to insurance on your own, Potomac Pediatrics will provide adequate documentation to aid in that process.

Unpaid Balances
Monthly bills are uploaded to the patient portal to alert the Guarantor of any unpaid balances.

Unpaid balances are aged to 90 days. After 90 days, any account with an outstanding balance will be assessed a collections fee of $9.50 and will be turned over to an outside collection agency. Should your account be sent to collections, all patients on the account will be discharged from the practice. If the account is turned over to a collection agency, the Guarantor is responsible for any fees incurred with the collection process. No patient will be discharged in the middle of a treatment plan; therefore, Potomac Pediatrics will allow the Guarantor 30 days to establish care with a new provider. During this time, Potomac Pediatrics will continue to provide any emergency care to the patient should care be necessary.

Payment Plans
In the event of financial hardship or other extenuating circumstance a payment plan can be arranged to keep the account current. Payment plans are individualized and may be set up over the phone with our billing department. Payment plans must provide for the payment in full of any unpaid balance. A valid credit card number is required to establish a payment plan: Payment plan payments cannot be made by cash or check.

Custody of Financial Responsibility Disputes
Potomac Pediatrics will not intervene in any custody dispute or financial responsibility dispute. We will upload statements to the patient portal only; it is up to the guarantor to insure timely payment is made for services rendered. OR In the care of estranged or divorced parents, the parent accompanying the child to the visit is responsible to pay for services rendered. The accompanying adult is responsible except when a certified legal document outlining the financial agreement is on file.

Questions and Concerns
Please discuss all insurance problems and financial agreements with the billing office staff. The billing office is available by phone, during regular business hours, to discuss charges, insurance questions, the status of your account, and payment options. For your convenience, you may email questions to billing@potomacpediatrics.com. Return calls/ email may take up to 3 business days.