BACK TO BASICS PEDIATRICS, SC PAYMENT POLICY

 

 

 

This is to inform you of our Back to Basics Pediatrics billing system. We will be using an outside agency through our Electronic Health System software. Our Pediatric Billing Service (PBS) will process your claims and send out invoices monthly on our behalf.

 

We would appreciate all outstanding payments to be paid within a 30 day time period. Copays will be collected at the time of service.

 

PBS will continue to send invoices up to 90 days. At that point, your account will be forwarded to our office for further collection of outstanding payments. If unable to reach an agreement on paying the outstanding balance, your account may be subject to collection by an agency.

 

Checks with insufficient funding will be subject to a $20 fee.

 

NO SHOW appointments will be charged $50 for repeated missed appointments.

 

By signing below, you have agreed to the terms of our Pediatric Billing Service policy.

 

 

 

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Date______________________________________

 

 

 

Thank you for your cooperation and for allowing us to care for your children!

Back to Basics Pediatrics, SC

2403 Harnish Drive, Suite 101
Algonquin IL  60102

HOURS:

Monday & Wednesday 9-5pm

Tuesday & Thursday 10-7pm

Friday 9-1pm

Saturday 9-12pm

office phone: 224-333-0730

©2018 by Christine Poulos, MD - Back to Basics Pediatrics, SC. Proudly created with Wix.com

fax: 224-333-0748