Time of Service and Financial Policy Form


Pediatric Effective Elimination Clinic (PEEP Clinic)

Financial Policy – Payment Plans, Collections & Time of Service Discounts

Our Office Policy Regarding Insurance Assignment

Our office is happy to accept your insurance assignment, as soon as your exact coverage is verified by the responsible insurance party. The deductible and any amount that is not paid by the insurance company are the patient’s responsibility. The patient will be billed for any balance not paid by the insurance company within 60 days, unless other arrangements are made with the PEEP Clinic. We will file your claim forms and assist you in every way we can.

Please be aware that some insurance companies/plans require a pre-authorization or referral prior to being seen at our office. You are responsible for obtaining the necessary documents and providing them to our office within 5 days of your visit. You are also responsible for verifying that we have received them. Failure to provide required documents will result in non-payment from your insurance company and balances will become patient responsibility.

Payment Plans

1). Extension of a Payment Plan to a Patient:  Our office grants payment plans on a case-by-case basis to patients. Written and/or verbal authorization from our office must be granted. We are legally and ethically obligated to collect all payment plan balances.

2). Minimum Monthly Payments:  The minimum monthly payment for a patient requesting a payment plan is 20% of the current balance monthly.

3). Good Faith Effort: Care will not be terminated as long as a good faith effort is made monthly to pay the balance.  This involves consistent monthly payment of a minimum of 20% of the balance.  The patient will be given 1 warning at the 90-day mark past due and sent to collections the following month (30 days after the warning is issued or 120 days after failing to make a payment).   The entire balance will be due if a patient is sent to collections.  For more information on collections read the info below.


1). Candidates for Collections:  We do not wish financial harm to our patients; however, we are legally, contractually and ethically obligated to collect patient balances.  Failure to make a good faith effort to collect patient balances violates the terms and conditions of the network participation agreements that we have engaged in.

2). 30 and 90 Day Warning & 120 Days Sent to Collection:  Patients will be sent to collections if there is no payment on the account for a period of 90 days or if insufficient minimum amounts (less than 20%) are collected monthly.  At the 90-day mark patients will receive communication (phone call, email, or written letter) that their balance is past due and given a warning.  At the 120-day mark, the balance will be sent to collections with the entire balance due upon receipt.  Patients sent to collections risk having their credit impacted.

3). Collections Fees:  Our office will incur fees if the balance is sent to collections.  Typical collections fees range from a flat dollar amount to 20-35% of the balance.  These fees will then be transferred into the patient’s balance raising the cost owed to our office.  It is in the patient’s best interest to make prompt, routine payments to avoid unnecessary fees.


What is a Time of Service Discount?

Whether your insurance covers pediatric elimination services or not or you do not have insurance, PEEP Clinic offers a Time of Service (TOS) Discount to everyone. National time of service discounts ranges between 5-20%.  Our time of service discount is 20% if you choose to pay for your services with this method of payment. In order to qualify for this discounted payment option, you would have to agree to the following:

1). All services are paid THE SAME DAY they are provided (at the discounted rate). We cannot extend a time of service discount to patients that pay after the service is rendered or those on payment plans.

2). You would submit to your insurance company the paperwork for the services provided at our office. We would not do this on your behalf but we will gladly provide a receipt of payment along with the proper medical billing codes for any treatment done. Your insurance company will reimburse you at a later date for the services performed in our office.

3). Only accounts in good standing will be eligible for the Time of Service discount

Click here for the disclosure form regarding Out-of-Network Healthcare Services and Out-of-Network Suprise Billing effective January 2020.

  • My signature on this document implies that I have read the above and understand my options for payment of services rendered at PEEP Clinic. It also implies that I understand that there is a $50 No show fee chraged for appointments that are missed with no notice or less than 48 hours notice.