Thank you for choosing the Pediatric Effective Elimination Program Clinic and Consulting, PC to care for your child. You and your child are important to the clinic and we want you to understand your rights and responsibilities as we team to care for your child. Your signature on this form provides consent for treatment and payment, and is an acknowledgment of the privacy practices of the clinic.
Consent to Treat
I consent to and authorize any member of the provider of the Pediatric Effective Elimination Program Clinic and Consulting, PC to perform healthcare examinations, treatment, diagnostic testing, transfers and referrals as deemed medically necessary in their professional judgment.
Assignment of Benefits and Release of Information
We gladly accept most major health insurance. Please contact us for more information. If we accept your insurance the following Assignment of Benefits and Release of Information will be in effect.
Except as prohibited by any agreement between my insurance company and PEEP or by state or federal law, I agree to be responsible for my co-payments, deductibles, or other charges of PEEP and of providers rendering services not covered or paid by insurance to other third party payors. I authorize PEEP to file any claims for payment of any portion of the patient bills and assign all rights and benefits payable for provider services to the provider or organization providing the services. I further agree, subject to state or federal law, to pay all costs, attorney fees, expenses, delinquent charges and interest in the event PEEP has to take action to collect same because of my failure to pay in full all incurred charges within 60 days after receipt of the bill. I understand that there will be a $25 charge incurred on all returned checks.
The term of this AoB and RoI will be until final payments are made for any and all services.
If and when there are changes to my insurance plans, I will notify PEEP staff and sign a new agreement.
I understand that PEEP is a fee for service program and I am fully responsible for paying for my child’s treatment before services are rendered. The initial visit is approximately 1 hour and all follow up appointments are approximately 30 minutes. All communication in between visits is included in the visit fees and incurs no cost. Monies are accepted as cash, credit card or check, and checks should be made to PEEP Clinic. I further agree, subject to state or federal law, to pay all costs, attorney fees, expenses, delinquent charges and interest in the event PEEP has to take action to collect same because of my failure to pay in full all incurred charges within 90 days after date of visitl. I understand that there will be a $25 charge incurred on all returned checks. There will be a $25 cancellation fee for appts canceled within 48 business hours and a $50 fee for no shows.
Notice of Privacy Practices