Illini Pediatrics LLC, DBA Ideal Pediatrics

Patient Name/s * Patient DOB *

Parental Consent to Treat

As the parent or guardian of the minor I authorize the onset to any examination, anesthetics, medical or surgical diagnostic or treatment procedures deemed necessary for the treatment of my child by any and all providers of Ideal Pediatrics. I understand that all treatment will be discussed and consent given at the time of treatment, unless an emergency situation dictates otherwise.

No Show Policy

We understand that circumstances arise that do not allow you to keep your appointment. If you need to cancel, we ask that you call at least 24 hours prior to your appointment time. You can leave a voicemail to cancel the appointment. Also, arriving more than 15 minutes late will count as a ?no show?, and in most cases we will not be able to see your child. Arriving without a copay will also be counted as a missed appointment.

No Show Fees: Charges will be assessed per child. 1st & 2nd missed appointments: $75 each. 3rd missed appointment: $75 and you will have a 30 day period to find a new pediatrician.

If you have extenuating circumstances that cause you to miss an appointment, please let us know.

Credit Card on File Policy

We now use a Credit Card Merchant Service called Anovia, which gives us the ability to swipe your credit card, debit card, or health savings account card to accept payment in the office and have the number securely stored on a remote server with Swipe Simple. The full Credit card number is not visible to us and is not stored in our office.

We require your credit card information to be stored for future payment for some of the following reasons: ** Your insurance company may not reimburse us for medical services, or only make partial payment because of the following: -Deductible has not been met for the current calendar year - Co-insurance may be applied to the charges - Service may be deemed as not a payable benefit for your plan. - Policy has terminated, or there is a gap in coverage - Newborn has not been added to the policy and are not covered under parents benefits ** You may have a copayment for medical services **You wish to set up a payment plan for a large balance on an account**You miss and appointment without giving 24 hours noticed not have your copay, or you are over 15 minutes late for an appointment

We will notify you of your balance with one statement sent to the address on file after receiving the explanation of benefits from your insurance company clarifying the reason for the balance for the account(s). Once notified, you will have 7 days to discuss any questions or concerns regarding your balances with us, or you can contact us with alternate payment. Please ensure your mailing address is up to date with our office. If we do not hear back from you, or you do not pay your balance within the 7 days, we will automatically charge your card for the amount due on the account(s). (No Shows will not receive a statement. No Shows will be charged on the next business day)

Financial Responsibility Policy

I understand that payment of all medical care is due at the time of service. In the case of divorced parents, responsibility and payment shall be that of the guardian bringing the child in for treatment. I understand that it is my responsibility to pay any deductible, co-insurance, or any other balance not paid by my insurance company. I understand that I am responsible for any costs incurred in the collection of patients account in case of default, including reasonable attorney fees and court costs. I hereby gran permission to Ideal Pediatrics to release any pertinent information to my insurance company upon request, and I also authorize payment directly Ideal Pediatrics. A photostatic copy of this authorization shall be considered as effective and valid as the original.

Notice of Privacy Acknowledgement

As the parent or guardian of the minor, I acknowledge I have received from Ideal Pediatrics, LLC a copy of their Privacy Notice, No Show Policy, Credit Card On File Policy, Financial Responsibility Policy and Billing Policy. I understand it is my responsibility to read the notices and ask questions as necessary.

Signature * Name of person filling out this form Todays' date