Zanesville-Pediatrics-Dr-Gupta-Collet-GiGi-Hernandez

Office Policies

Vaccinations

Zanesville Pediatrics is only able to accept patients who are willing to be vacinated.

Payment

Payments for services are due at the time service is rendered

Insurance

Zanesville Pediatrics will bill patients insurance for services rendered. Insurance copayments are due prior to the appointment and deductible and co-insurances are due at the time that the patient receives the first bill. After 90 days of no response for payments, accounts will go to collections and the patient could be discharged from the practice.
We encourage our patients to contact their insurance company to clarify coverage.View Accepted Insurance

Self-pay

Payment in full is expected at the time of service. We offer prompt pay discounts providing significant savings.

Demographics

It is the patients responsibility to make sure that the office has their most up to date information (phone number, address, insurance information. If the patient does not have an updated insurance card, they have the option of paying in full at the time of service or rescheduling when they do have it. *Please have insurance cards ready at every visit.)

Non-Covered services

Any service deemed non-covered by the patients insurance carrier or denied (for any reason) will be the patients responsibility for payment in full. It is also the patients responsibility to know what is covered and what requires a prior authorization.

Annual Wellness Physicals

Patient understands that they are required to come in yearly for a well exam. A problem visit, ill visit or follow up can’t be included in the well visit. They must be scheduled separately and be billed accordingly. I understand that failure to get a well exam may result in termination from thereafter.

Medicaid Well Child Visits

Patient understands that the contract with Ohio Medicaid and their provider, that they will be required to have well visits a 2, 3, 6, 9, 12, 15 and 18 months and every year thereafter.

Hospital & ER Visits

Patient understands that any visit to the hospital or the ER requires a follow up visit to this office within 7 days. Failure to comply could result in dismissal from this practice.

ER Visits

Patient understands that they are expected to not abuse the ER for non-emergent problems and understanding that this could lead to dismissal from the practice.

Missed Appointments

Zanesville Pediatrics requires a 24 hour advance notice to cancel appointments. Patient understands that more than two no-show appointments in the office will require a $25 payment prior to any future appointments being scheduled. If the practice of no-showing for appointments continues, patient understands that they could be dismissed from the practice.

Refund Checks

Patient / Guarantor credits in amounts less than $20 will be retained on account to be credited toward future balances unless a written request for refund is received. Amounts $20 and greater will be automatically refunded to the patient / guarantor when reviewed at the end of each quarter.

Medications

Patient understands that it is their responsibility to discuss their medications at the time of their appointment including changes, side effects and needed refills. Please bring medications to each appointment for review.

Written Acknowledgement of Privacy Practices

Patient acknowledges that they have received a copy of Zanesville Pediatrics’ Notice of Privacy Practices, which explains ways in which their medical record information can be used or disclosed by the practice and also outlines patients rights to access this information.

Annual Patient Consent for Prescription and Pharmacy Transmission

Patient consents to the use of their medical information necessary for transmission of prescriptions to the pharmacy and as needed for the coordination of formulary and / or benefits eligibility with their insurance provider. Patient consents to the query of their external prescription history as necessary to manage their healthcare and related services.

Giving our young patients the personalized
pediatric care that they deserve

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