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Office Policies

Please fill out this form as completely as possible. It will be sent securely to our office.

Our goal is to provide and maintain a good provider-patient relationship. Letting you know in advance of our office policy ensures communication and enables us to achieve our goal. Please read each section carefully and initial. If you have any questions, please ask a member of our staff.

  • Appointments

    • We value the time we have set aside to see and treat your child. If you are not able to keep an appointment, we require a 24-hour notice. Multiple failures to give appropriate notice may result in dismissal from the office.
    • If you are late for your appointment (>15 minutes), we will do our best to accommodate you. However, on certain days it may be necessary to reschedule your appointment.
    • All children under the age of 14 must be accompanied by an adult.
  • Insurance Plans

    • It is your responsibility to keep us updated with your correct insurance information. Upon arrival we ask that you present your insurance card at every visit to verify that our office has the most updated card on file.
    • If the insurance card/plan you present is incorrect, you will be responsible for payment of the visit and to submit the charges to the correct plan for reimbursement.
    • If we are your primary care provider, make sure our name/phone number appears on your most up to date card. If your insurance has not been informed that we are your primary care provider, you may be financially responsible for your current visit.
    • It is your responsibility to understand your plan benefits. Not all plans cover well child visits, vision/hearing screenings, or physicals. If these services are not covered, you will be responsible for payment.
    • If your insurance plan allows a certain number of visits per year and those visits have been exceeded, you will be responsible for payment.
  • Financial Responsibility

    • According to your insurance plan, you are responsible for all co-pays, deductibles, and coinsurances.
    • Co-pays are due at the time of service. A $15.00 service fee will be charged in addition to your co-pay if not paid at the time of service.
    • Self-pay patients are expected to pay for services in full at the time of visit. This includes patients with out of network insurance plans. Our office will be happy to provide the necessary documentation for you to file the claim for reimbursement with your insurance company.
    • Patient balances are billed monthly. We ask that you pay your statement balance after receiving your first statement. A 20% surcharge will be assessed on all balances over 60 days old.
    • If previous arrangements have not been made with our finance office, any account balances over 90 days old will be forwarded to a collection agency and all collections expenses will become your responsibility.
    • Any accounts that have been transferred to collections will need to provide a credit card on file to continue a relationship with Fairhope Pediatrics.
    • For scheduled appointments, any outstanding balances must be paid prior to the visit or you will be asked to reschedule.
    • We accept cash, check, and all major credit cards.
    • A $30.00 fee will be charged for any checks returned for insufficient funds and checks will no longer be permitted as a method of payment.
    • A $25.00 fee will be charged for any declined credit cards and credit card chargebacks.
    • You are financially responsible for any vaccine that you have consented to for your child once that vaccine has been prepared by Fairhope Pediatrics staff, whether the vaccine dose is completed. Refusal or failure to cooperate with the vaccine will result in a charge to your child’s account equal to the CDC Private Sector price (available on request) plus a 20% service fee.
  • Wellness Care

    • Wellness care is an essential part of keeping your child healthy and regular check-ups are required by Fairhope Pediatrics. Patients who do not have preventative coverage can receive this service at a discounted rate if paid at the time of service.
    • Most insurance companies cover most CHADIS questionnaires; however, it is the patient’s responsibility to verify coverage with their insurance company. If any questionnaires are denied by insurance, the cost will be the patients responsibility.
    • All CHADIS questionnaires will need to be completed 24 hours prior to the scheduled appointment time. Failure to do so will result in having to reschedule the appointment.
  • Referrals

    • Advance notice is needed for all non-emergency referrals, typically 2 business days.
    • It is your responsibility to know if a selected specialist participates with your insurance.
  • Forms

    • There is no charge for a certificate of immunization given at the time of your child's visit. There is no charge for 1-2 page physical or medication forms presented at the time of visit.
    • Any additional school, camp, sports forms, or forms exceeding 2 pages are subject to a $7.00 flat fee plus $3.00 per page for filling out the form. We require a 72-hour turnaround time.
  • Medical Records

    • Copying of medical records is available with a $5.00 flat fee plus $1.00 for pages 1-25 and $0.50 for pages 26 and over. Records will be available for pick-up in the office.
    • We provide records of your child’s visits with Fairhope Pediatrics, Inc. only. All records for outside facilities or providers should be obtained from them directly.
  • Prescription Refills

    • For monthly medication refills, we require 48-hour notice, during regular business hours. Please plan accordingly.
  • Signature

    I have read and understand this office policy and agree to comply and accept the responsibility for any payment that becomes due as outlined in this document.
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