Office Polices

Kintiroglou Pediatrics
1500 Pleasant Valley Way, Suite 301 West Orange, NJ 07052 973-243-0002
Kintiroglou Pediatrics goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our Office Policy, allows for a good flow of communication and enables us to achieve our goal. Please read this carefully and if you have any questions please so not hesitate to ask a member of our staff.
1. Upon arrival, please check in and present your current insurance card at every visit.

2. It is your responsibility to understand your benefit plan. It is your responsibility to know if a written referral or authorization is required to see specialists, if preauthorization is required prior to a procedure, 48 hour advance notice is required for all non-emergent referrals.

3. According to your insurance plan, you are responsible for any and all co-payments, deductibles and co-insurances.

4. If our physicians do not participate in your insurance plan, payment in full is expected from you at the time of your office visit unless other arrangements are made. For scheduled appointments, outstanding balances must be paid prior to the visit.

5. If you do not have insurance, payment for an office visit is to be paid at the time of the visit.

6. Co-pays are due at the time of service.

7. Patient balances are billed immediately upon receipt of your insurance plan’s explanation of benefits. Your remittance is due 10 business days from receipt of your bill.

8. We reserve the right to charge an administrative fee per month as provided by state law for all past due balances.

9. Kintiroglou Pediatrics will not fill any prescriptions or complete any forms if your last physical is ove one (1) year old.

10. A $30 fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.

11. We charge $1.00 per page for Medical Record copying up to 25 pages and .25 for each additional page.

12. If your child has school forms, camp forms, sport forms, etc. to be completed, there is a $10 charge per form. Payment is due when the forms are dropped off as well as a self-addressed stamped envelope. We require a minimum one week turnaround time for those forms.

I have read and understand the above Office Financial Policy and agree to comply and accept the responsibility for any payment that becomes due as outlined above.

Signature of Patient or Responsible Party
Date of Signature

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