Financial Payment Policy for Carmel Pediatrics

The purpose of this form is to clarify to you our stand on filing insurance, completing health forms, transferring records and collecting payments on your account.
REGARDING INSURANCE: Our office participates with many insurance companies, should your insurance be with one or more of these companies, we will bill your insurance along the guidelines of our contract.
A current copy of your insurance card(s) must be on file to submit a claim.
 If the correct insurance information is not given to Carmel Pediatrics and your medical claim is denied you will be responsible for payment in full for services rendered and/or for a $25.00 fee to re-file to the correct insurance company.  Insurance information submitted to us past the timely filing date, will be your full responsibility.

The party which seeks medical care and signs the financial policy is considered the “guarantor” and financially responsible for payment , regardless of any divorce decree or court order. This includes services rendered to minors who may be covered by another parent’s insurance under a custody agreement.

REGARDING BALANCES DUE ON ACCOUNT: The balance due after the insurance company has paid their portion is due within 30 days. If you are unable to make payment in full you will need to call the office and make payment arrangements. Your account may be assessed $20.00 per month for every month we send a statement 30 days after the insurance company has paid.  After 60 days you risk your account being sent to the collection agency.

REGARDING ACCOUNTS THAT GO TO COLLECTIONS: If your account goes to the collection agency your child(ren) will be seen for 30 days, only for urgent care. You will need to find a new physician to care for your family. In the event your account is submitted for collection, you will be charged a fee of $25.00 to collect for services, and any additional fees required for court judgment or otherwise.

REGARDING TRANSFER OF RECORDS: There is a charge of $25.00 per chart to transfer records. This will need to be paid prior to the transfer.

REGARDING HEALTH FORMS: There is a $5.00 fee per health form. You are required to complete your portion of the health form before you bring it to the office for completion. It takes 5-7 business days to complete a health form. Should you need to have the form completed within 24 hours there is a fee of $15.00 per form.

NON-SUFFICIENT CHECKS/CLOSED ACCOUNTS: Your account will be charged $35.00 for a check returned for non-sufficient funds, closed account, etc. You are still responsible for the amount of the check and if payment is not made, your account may be subject to collection process as defined above.


  • There may be a $25.00 fee for any appointments not kept without at least a 24 hour cancellation.
  • There is an additional fee if your child is seen for urgent care on a date that we do not have normal office hours. (i.e. holidays)

Financial Hardship: There are times when making payment can be a financial hardship. It may be necessary to set up a payment plan for the parent who cannot comply with our financial policy. If you are in need of special payment arrangements, please advise our staff prior to your visit. Co-pays are exempt from this because your insurance requires you to pay your co-pay at the time services are rendered.  Co-pays not paid at the time of visit are subject to $10.00 late penalty.