Policies

We work hard to not overuse antibiotics.

We educate families on appropriate use of antibiotics, but follow evidence-based guidelines and don’t automatically treat ear pain or a green snotty nose with antibiotics.

We do not routinely prescribe antibiotics over the phone as we do not believe that is good medicine. We will prescribe an antibiotic when we believe it is an appropriate treatment.

Everyone's Time is Equally Valuable.

We ask that you arrive 5 minutes before your scheduled appointment time. We understand sometimes things happen beyond your control that may cause you to be late. However, we reserve the right to ask you to reschedule if you arrive late for your appointment.

Our practice makes every effort to run on time with appointments, as we believe everyone’s time is equally valuable.

Upcoming Appointments Via Phone/Text Message/Email

Missed Appointments: Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. We reserve the right to charge a $50 fee for missed appointments or cancelled less than 24 hour notice. We request 24 hours notice for cancellation of appointments.

The second no show or  missed appointment will result in discharge from the practice.

For new patients, a fee of $50 will be charged  and the appointment will NOT be rescheduled if the FIRST appointment is missed.

EAST AURORA PEDIATRICS FINANCIAL POLICY

Welcome to East Aurora Pediatrics.  In order for our medical staff to be able to deliver the quality of care that you are accustomed to, we have established our financial policies.  The following is a list of guidelines that are necessary in order to continue to provide high quality care and make your visit as pleasant as possible.  

PLEASE READ ALL INFORMATION AND ACKNOWLEDGE BY SIGNING BELOW:

1. We ask that you present your insurance card at each visit. It is your responsibility to provide us with the correct information to bill your insurance.

2. If you have a change of address, telephone numbers, or employment, please notify the receptionist. 

3. All co-payments and past due balances are due and payable at the time of service. We accept cash, checks and major credit cards.  Ther is a service charge of $25 for returned checks.

4. If your account becomes delinquent we reserve the right to defer your account to a collection agency and to be reported to the credit bureau.

5. HMO_PPO PATIENTS: If we participate in your plan, we will bill your insurance for you. Your co-payment will be collected at the time of service-NO EXCEPTIONS. If your plan requires you to choose a primary care provider (PCP), it is your responsibility to make sure your insurance company has one of our physicians listed.  

NOTE: If you choose to pay for a visit in full, out of pocket, at the time of your visit, and you request that we do not bill your insurance company, you have the right to ask that your PHI, with respect to that visit, NOT be disclosed to your health plan for purposes of payment or health care operations and our practice will honor that request. 

6. SELF-PAY PATIENTS: Patients with no insurance will be expected to pay at the time of service.  IF you will not be able to pay in full, you must speak to our office manager or billing manager to make payment arrangements prior to seeing the physician, nurse practitioner or physician’s assistant.  

7. NO SHOW OR MISSED APPOINTMENTS:  When an appointment is scheduled with the physician, time is specifically allocated to you. When an appointment is not cancelled in advance and the patient “no shows”, another patient that needed to be seen may have been unable to because the time slot was already taken. We understand that an emergency may arise, but we ask the courtesy of a phone call to cancel an appointment. You will be charged a $50 fee for failure to keep an appointment.  If two appointments are missed you will be dismissed from East Aurora Pediatrics for non-compliance.  

8. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.  It is very important that you understand the provisions of your policy. We cannot guarantee payment, reduction or rejection of your claim by your insurance; therefore, it does not relieve you of your financial obligations.

9. It is the policy and regulation of your HMO or PPO that a co-pay will be required if there is a separate identifying diagnosis made at the time of a routine well visit. 

Remember, whether you do or do not have insurance, you are ultimately financially responsible for payment of your charges.  If you have any questions regarding our financial policy, please contact our billing department at 716-652-0237 ext. 4.

NOTE:  In divorce cases, the adult seeking treatment is responsible for any co-pays due. If the court has awarded custody of minor children to one person and financial responsibility to another, the person bringing in the child is still responsible for payment of co-pays. You may bill your estranged; but it is NOT the responsibility of the practice.

I have read and have a full understanding of the financial policy of East Aurora Pediatrics.

Signature:______________________________

Patient’s Name:__________________________________

Date:___________________________________

EAST AURORA PEDIATRICS, P.C.

Patient consent for Use and Disclosure of Protected Health Information

Effective September 23, 2013

With my consent, East Aurora Pediatrics may use and disclose protected health information (PHI) about me (or my children) to carry out treatment, payment and healthcare operations (TPO). Please refer to East Aurora Pediatrics’ Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have reviewed the Notice of Privacy Practices prior to signing this consent. A copy is available in the waiting room to read here or take home.  East Aurora Pediatrics reserves the right to revise its Notice of Privacy Practices at any time.  A revised Notice of Privacy Practices may be obtained by forwarding a written request to East Auroora Pediatrics’ Privacy Officer at 94 Olean Street, Suite 210, East Aurora, NY 14052.

With my consent, East Aurora Pediatrics may call my home or other designated location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory and radiology results among others.

With my consent, East Aurora Pediatrics may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. It is my responsibility to notify East Aurora Pediatrics of any change of address, phone number, marital status and custody issued.

I have the right to request that East Aurora Pediatrics restrict how it uses or discloses my PHI to carry out TPO.  However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

Note:  if you choose to pay for a visit in full, out of pocket, at the time of your visit, and you request that we do not bill your insurance company, you have the right to ask that your PHI, with respect to that visit NOT be disclosed to your health plan for purposes of payment or health care operations and our practice will honor that request.

With my consent, East Aurora Pediatrics may fax to my child’s school or day care provider a copy of their immunization record and Health Appraisal Forms.

By signing this form, I am consenting to East Aurora Pediatrics’ use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.

______________________________________

Signature of Patient or Legal Guardian

______________________________________

Print Name of Patient Date

______________________________________

Print Name of Legal Guardian Date

Efficiency through the use of technology

You will be encouraged to consult our website, register for and use our patient portal, and effectively use automated reminders for appointments and for routine care/immunizations that are due.

As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We are more than willing to discuss any questions you may have about vaccines, but do require all new patients to our practice to adhere to the vaccination schedule endorsed by the American Academy of Pediatrics (AAP).