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 Annual Non-covered Service Fee (NCSF) to insurance. Therefore, the guarantor is responsible for payment of this fee, in full, at the beginning of each NCSF calendar year (see “Non-Covered Service Agreement” under Provided Services for more information). The NCSF is non-refundable and is not a pro-rated fee. Should you leave the practice during a NCSF year a refund will NOT be issued.

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 $35: The account will be debited for this amount on top of the original amount of the transaction. After one returned check, 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. Copays are due at the time of service and will not be billed to you. If you have a deductible, then a deductible deposit will be due at the time of service, for each visit, and each child until your deductible has been met. The deductible deposit is based on the contracted rate with your insurance carrier.

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.

Preventative Care Visits & Sick Visits

Preventative (well child) visits are separate from sick visits. We understand that due to convenience many patients wait for an upcoming appointment to discuss medical concerns or obtain additional prescription refills that are separate from well child care. When this occurs your provider will bill your insurance for an office visit which will prompt a copay or deductible balance. When you receive your statement (and EOB) you will see the charges and corresponding patient responsibility.

Late Cancellation/ Missed Appointments

  • Sick Visits (Regular/Detailed)- Appointments that are canceled with less than 24 business hours advanced notice will be subject to a $50-$75 fee.
  • Well child exams, pre-ops, behavioral consults, and medication checks – Appointments that are canceled with less than 24 business hours advanced notice will be subject to a $100 fee.
  • Derm/Acne- Appointments that are canceled with less than 48 business hours advanced notice will be subject to a $150 fee.
  • Psychiatry Evaluations- Appointments that are canceled with less than 48 business hours advanced notice will be subject to a $250 fee.
  • Psychiatry Med Checks- Appointments that are canceled with less than 48 business hours advanced notice will be subject to a $150 fee.
  • Therapy Sessions- Appointments that are canceled with less than 48 business hours advanced notice or no showed will be subject to a $150 fee.

Patients who have an excessive amount of late missed or combination will be subject to discharge from the practice.

Click here for a full description of our missed appointment and late cancellation policy.

Classes & Seminars: We ask that if you register for a class, please attend or cancel your reservation within 24 hours of the event so another parent on our wait-list may take your place. Due to the high number of no-shows at these FREE events, a no-show fee will be charged to your credit card on file. The following charges will apply:
Classes led by:

  • Potomac Pediatrics Nutritionist: No-Show Fee: $25
  • Ancillary Classes & Seminars Led by Potomac Pediatrics Staff: $25
  • Ancillary Classes & Seminars Led by Community Specialists: $25

Billing Cycle
Statements are uploaded to the patient portal to alert the Guarantor of any patient balances within 7 days of receiving claims back from your insurance company. All patients are required to keep an active credit card on file for patient balances. Patients are responsible for reviewing their statements and notifying our billing department within 7 days of that statement if they have any inquiries or disputes. Your credit card will be charged for the full statement balance 10 days after your statement has been generated.

Credit Card on File Authorization & FAQ’s

Unpaid Balances
Declined credit cards that are not updated within 24 hours are subject to a $25 declined credit card fee. Balances that go unpaid for 2 statement cycles will be subject to a $25 late fee (on top of your declined credit card fee). 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 medical care be necessary.

Payment Plans
In the event of financial hardship or other extenuating circumstances, 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. Failure to make a payment as agreed will void your payment plan and your balance will be due in full.

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 ensure 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. If there is such a financial agreement in place, the financially responsible party must make payment arrangements prior to the visit.

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 We do manage all patient billing in our office, so please allow all calls and/or emails up to 3 business days to be returned. Inquiries regarding an upcoming credit card on file charge will be given priority and will be returned within 24 hours.