BUSINESS OFFICE

Statement of Financial Policy

Our primary interest at NACS in in taking care of your child. However, we must enforce our financial policy in order to continue to provide your child with the best care possible. By signing as responsible party you are acknowledging the following statement.

I have read the Statement of Financial Policy. I understand and agree to the policy.

Methods of Payment
We accept cash, personal check, and credit/debit cards (MasterCard, Visa, American Express, and Discover).

Demographic Updates/Responsible Party
Please notify our front office staff if there are any changes to your insurance policy, address, and/or phone number. In order to maintain current records we require that the responsible party complete and sign a demographic form annually. The person who brings the child for treatment and signs the paperwork is the responsible party. In circumstances where parents are separated or divorced, NACS will not act as a mediator in collecting payment.

Insurance
We will accept and file claims with any insurance carrier with whom we are a participating provider. As a courtesy to our patients we will also file claims with non-participating carriers. Filing a claim does not guarantee payment. It is the responsibility of the cardholder to know what their eligibility and coverage is. If this is not known it is the cardholder's responsibility to verify coverage limitations prior to the appointment date.

Payment Arrangements/Past Due Accounts
Please call our Business Office if you have questions regarding your account balance. Payment arrangements can be arranged if needed. Statements are mailed monthly. If your account balance becomes past due, appropriate action will be taken to collect the amount due. Accounts that are overdue more than 90 days will be turned over to a collection agency. At that point, you will be responsible to pay the account directly to the collection agency and any fees due to them.

Referrals
It is your responsibility to ensure that all necessary referrals from the correct assigned Primary Medical Provider are in place. Some insurance companies including Medicaid will not pay specialized services without a referral. Any payment denied for lack of referral will be forwarded to the responsible party for payment.

Financial Assistance

You may be eligible for financial assistance under the terms and conditions the hospital offers to qualified patients. For Children’s Financial Assistance Policy contact 1-844-750-8950 or contact the Business Office at 205-638-2722. You can also visit www.childrensal.org/financial-assistance for additional information.

Non-Covered Services & Additional Charges

Processing Fee
Copays/Coinsurance, dedcutibles, and non-covered services are due in full and payable at the time service is rendered. A $10 processing fee will be charged to your account if payment is not made at the time of service.

Returned Checks
There is a $25 fee for all returned checks

No-Show Appointments
There is a $25 fee for all "no show" appointments. As a courtesy we provide an appointment reminder slip at check out and a call reminder four days before your appointment. We can also send email reminders of your appointment. Although our office provides these reminders for you; it is ultimately your responsibility to inform the office of cancellations/reschedules within 24 hours to avoid being considered a "no show." More than two "no-shows" annually may result in dismissal from the practice.

Medical Records
Please contact Medical Records for all requests.

Forms
A $5.00 form fee will be charged for all forms requested outside of an office visit. Allow 48 hours for your request to be processed. There is no charge for work/school excuses. Please remember to request these at check-out.

In order to protect the privacy of our patients we do not fax forms. Forms can be mailed to your home address if the form fee has been paid.