Secure Forms

Financial Policy

Thank you for choosing Pediatric Professional Association as your child’s health care provider. The following is a statement of our financial policy. We require that you sign and acknowledge this policy.


According to most health insurance policies, babies must be added to the parent’s policy within the first 30 days following birth. If this is not done, your insurance may not cover your child and you will be financially responsible for the cost of all care provided, in the office as well as in the hospital, by Pediatric Professional Association physicians.

Health Forms/ FMLA Forms:

Please note there is a $10 charge to fill out health forms if they are not brought at the time of your child’s physical. If the health form is needed on a same-day basis, there is a $15 charge. There is a $25 fee for FMLA forms.

Medical Records:

There is no charge for first two requests of the DRS (Designated Record Set) which includes the: progress notes, immunization records, growth chart, and health maintenance record. There is a fee for additional DRS requests as well as for complete record requests. The fee currently is $17.50 for materials and labor plus $0.58 per page for the first 250 pages, and $0.41 per page thereafter. The fee for the Mental Health Summary (includes psychological testing) is $50.


From time to time it will be necessary for PPA to refer your child to an outside lab and/or specialist for further evaluation. While we make every attempt to insure this facility/physician is in-network with your insurance company, it is ultimately YOUR RESPONSIBILITY to make sure this is the correct facility/physician with your plan. If there are any discrepancies you should advise our office BEFORE proceeding so we can assist you with any necessary changes. PPA will not be financially responsible, under any circumstances, should you go to an out-of-network facility or physician.

Saturday Appointments:

There is a $15 fee for all Saturday appointments with a provider. We will submit this charge along with all other charges incurred for the appointment to the insurance company. However, if this fee is denied, not allowed, or not covered by insurance you will be responsible for this fee. A fee will not be assessed for immunization only appointments.

After-Hours Telephone Calls:

As of July 1, 2016 PPA will charge $10 for after-hours telephone calls.

After-Hours Convenience Fee for Prescription Refills:

As of July 1, 2016 PPA will charge $25 for any patient request for prescriptions after hours. We ask for 72 hours’ notice for refills. This fee will be waived for prescriptions that were to be sent during office hours that failed to be received by the pharmacy.

Missed Appointments:

A $25 fee will be charged when a scheduled appointment is not cancelled or rescheduled ONE hour prior to the appointment time. We attempt to confirm appointments, but remember this a courtesy and it is your responsibility to know the appointment time.

Divorced Parents:

Pediatric Professional Association will not get involved in custodial, separation or financial disputes. The individual bringing the child in for services is responsible for payment of any unpaid charges on the account, as well as any applicable copay due at that time. We will be happy to furnish you receipts so that you may be reimbursed.

Insurance Benefits:

Your health insurance policy is a contract between you and the insurance company. It is your responsibility to know your benefits, as well as if PPA is in-network and participates with your insurance company. We will attempt to bill your insurance company for all services rendered in our office. Any denied services or any balance remaining following adjudication of the claim is your responsibility.

Credit Card on File:

Pediatric Professional Association requires that all patients maintain a valid credit card on file with the practice. Any patient balances that are not paid in full by 29 days of PPA’s receipt of the explanation of benefits, from the insurance company, will be automatically charged to the credit card on file. If the credit card is not valid at the time the payment is charged, the balance will be due in full within 2 business days. A valid credit card will be required to be kept on file in place of the invalid card before the child can be scheduled for a routine appointment.

Return Checks:

A $25 fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.

Delinquent Balance:

Every attempt is made to ensure your account does not become delinquent. Your account will be considered delinquent at 60 days from date the office receives the insurance explanation of benefits. Balances that are not reconciled within 90 days may be referred to an outside collection agency.

Outside Collections and Bankruptcy:

If a collection agency or attorney becomes necessary due to non-payment, you will be charged for all fees incurred by PPA as a result of using a collection agency or attorney. Collections can result in discharge from the practice. Bankruptcy is considered a form of non-payment and can result in discharge from the practice.