immunizations newborn notification

Harlingen Pediatrics Associates
321 S. 21st. Street, Harlingen, Texas 78550
(956) 425-8761.
. www.myhpa.org
Thank you for choosing Harlingen Pediatrics as your health care provider. We are committed to
providing the best medical care to your family. The following statement explains HPA's Financial
Policy which we ask you to read, sign and return to us prior to your visit.
CO-PAYMENTS/DEDUCTIBLE S
A large number of insurance plans require their members to make a co-payment whenever they
seek medical attention. It is a violation to your contract to refuse to make your co-payment when
checking in with the receptionist.
INSURANCE
We participate in numerous insurance plans (for a complete list, plase ask the receptionist). We
try to contact your insurance company prior to the appointment, however it is still your
reponsiblity to understand and comply with any predetermination of benefits. Please be aware
that some and perhaps all of the services provided may be non-covered services or may be
considered medically necessary under your specific insurance plan. (Piease ask our Benefit
Representative for clarification on your plan).
IMMUNIZATIONS
Immunizations represent one of the most important aspects of your child's preventive care. Your
insurance maylmay not cover all immunizations or it might have an age limit restrictions. There
may also be a dollar limit restriction. You may qualify for the Vaccine for Children Program if
you have medical insurance or your insurance does not cover immunizations. (Please verify by
asking our Benefits Representive).
MIS SED/LATE APPOINTMENTS
Arriving 15 mintues after your appointment time may be considered a missed appointment, no
show. Please make every effort to arrive within 15 minutes of your assigned appointment.
Twenty four (24) hour advance notice is required if you are unabie to keep appointment. Failure
to notify us of a cancellation may affect your abilty to schedule future appointments, you maybe
expected to pay a no show fee.
NEWBORN NOTIFICATION
We advise parents to inform their hospital discharge. Insurance/Medicaid will not add newborns
or pays for claims without prior notice notification.
RETURNED CHECKS
A1l returned checks will be assessed a $30.00 fee. Cash or money order will be accepted for those
accounts with more than2 returns'
Name
Patient Name
Date
Signature
Date of Birth
HATTLINGEN PEDIATRICS AS SOCIATES
321 S. 21.ST. STREET, HARLINGEN, TEXAS 78550
(956\ 425-876]
Gracias por escoger a Harlingen Pediatrics Associates como su proveedor de servico
medico. Estaremos comprometidos en proporcinale el mayor service medico a sus
pequenos. Por favor comprenda que el page de su factura es tambien considerado parte
del tratamiento. La siguiente declaracion explica el plan de accion finaciero, le pedimos
que 1o lea, frime, y regrese a la recepcionista.
PRE-PAGOSIDEDUCIBLE
Un gran numero de seguros requieren que sus participantes pre-pagan su visita coundo
busquen attencion medica. Es una violacion a su contrato el rehusar o hacerlo; por favor
este preparado para propocionar su pre-pago con la recepcionista.
SEGURO
Participarmos en numerosos planes de seguro (pregunte a la recepcionista por una lista)
tratamos de ponernos en contacto con su compania de seguro antes de su cita, sin
embargo es su responsabilidad el entender y compiir con cualquier pre-determinacion de
beneficios o requeriminetos cuando referios a otros especialistas. Algunos o quizas todos
los sevicios que se le han proporcionado pueden no estar cubiertos o sean no
considerados medicamente necesarios en su plan. (Favor de dirigir preguntas o
clarificaciones con nuestra representante de beneficios)-
VACUNAS
Las vacunas representan uno de los aspectos mas importantes en ei cuidado preventivo
de su ]5tjolhija, a veces su seguro puede o no, cubrir las vacunas, puede tener restriciones
de limite de edad o contidad monetaria. (Favor de informase con el representante de
seguros).
FALTAR A CITAS
Puede ser que haiga un cargo de $25.00 dollares por cada vez que falte a una cita que no
haiga sido cancelada. La tercera falta que no halla sido cancelada como resultaldo
resultara con el paciente sea dado de alta y retirado de la lista por incumplimiento.
NOTIFICACION DE RECION NACIDOS
A consejamos a los padres notificar a su compania de seguros/Medicaid del nacimiento
de su recien nacido inmediatamente despues de ser dado de alta del hospital. Los
seguros medicos/Medicaid no cubriran ninguna factura sin antes haber sido notificados
del nacimiento.
DEVOLUCION DE CHECQUES
A todos devolucion de cheques se le agregarauna cargo de $30.00 dollares. Las cuentas
d.e mas de 2 ocasiones de cheques devueltos, tendran que liquidar la factura en efectivo o
giros bancarios soiamente.