- I have a right to be seen in a timely manner. I will be informed of any delay, and I have the right to reschedule if a delay is too lengthy.
- I will be informed of my child/children’s test results in a timely manner.
- I agree to be on time for my appointments and will pay a missed appointment fee for any appointment I miss if I fail to notify the office at least 8 hours in advance. Three or more missed appointments per family may also lead to dismissal.
- I understand that I am responsible for understanding the benefits of my insurance plan. It is my responsibility to determine what services are covered and/or not covered by my insurance plan. I understand that Sandhills Pediatrics does not provide care based on what my insurance does or does not cover. I hereby assign my insurance benefits to Sandhills Pediatrics.
- I understand that copayments are to be taken at check-in for any appointment and failure to pay the copayment amount at this time will result in a Billing Fee.
- I am ultimately responsible for the payment of the services my child/children receive. I understand that my co-payment, co-insurance and deductible are due at the time services are rendered. Sandhills Pediatrics accepts cash, checks, Visa, Master Card, Discover and American Express.
- I understand that any questions or disputes about my bill must be addressed with the Billing Department (803-788-6146). I understand that if I cannot afford to pay in full a bill I receive, it is my responsibility to contact the Billing Department to set up a monthly payment plan.
- I understand that Sandhills Pediatrics participates in the VFC program and that I am responsible for determining whether or not my child/children are eligible to receive vaccines through VFC.
- I understand that there is a charge for copying medical records.
- I understand that there may be a charge for completion of physical, camp, school and FMLA forms.
- I agree to pay a returned check fee for any check that is returned from my bank for insufficient funds.
- I understand that if I owe Sandhills Pediatrics a balance on my account for greater than 150 days I may be turned over to a collections agency. I agree to pay all costs related to assigning my account to an outside collections agency. I understand that if I am turned over to an outside collection agency I will be dismissed from all SCPA practices.
- I understand that Sandhills Pediatrics can only bill for the diagnoses and procedures documented in my child/children’s medical records and that to ask the doctor to change a diagnosis or procedure to secure insurance payment constitutes fraud.
