Parent Agreement

The parent agreement outlines a series of requirements that parents or legal guardians must commitment and consent to for their children to become patients of Salud Pediatrics. The agreement includes office and financial policies.
INSURANCE PLANS
I understand it is my responsibility to confirm with my insurance company that the physician is currently under contract with my plan or be willing to be seen under “out of network” benefits.
INSURANCE BENEFITS
COPAYMENTS | DEDUCTIBLES | COINSURANCE
DESIGNATED GUARANTOR
FINANCIAL RESPONSIBILITY
DEMOGRAPHIC VERIFICATION
VACCINE POLICY
PROOF OF INSURANCE
CREDIT CARD ON FILE
PATIENT RESPONSIBILITY PAYMENTS
EMAIL NOTIFICATION REGARDING PATIENT RESPONSIBILITY BALANCES
STATEMENTS & PATIENT PORTAL
DELINQUENT ACCOUNTS
RETURNED CHECKS
FORMS FEES
LATE ARRIVALS
NO SHOWS
MINORS