Personal Care Pediatrics, P.A.'S Financial Policy

Personal Care Pediatrics, P.A.'S Financial Policy

It is important to us that you understand our financial policy, and know that we are always willing to answer any questions you might have.

Our Policy

  • All patients/guardians must provide their personal information on their first appointment prior to seeing the physician.
  • All patients/guardians must have their insurance verified monthly prior to seeing the physician.
  • All the co-pays, deductibles and balances are due at the time of service.
  • All patients/guardians must sign this financial policy statement and must be updated yearly.
  • If you write checks for accounts with insufficient funds we will take legal action, and will bill you a $40 service charge for each bad check.

Insurance Coverage

  • You should be fully familiar with your insurance policy including participating hospitals and laboratories, and whether your plan requires referrals to see specialists.
  • Insurance is a contract between you, your employer, and the insurance company. As part of this contract, we are required as providers to collect all co-pays, deductibles, and balances.
  • Not every insurance company will cover all the services that we perform. This office does not always know what different insurance companies will pay. By signing this document, you are agreeing to pay for all coinsurance, deductibles, co-pays and non-covered charges that your insurance company deems are your financial responsibility to us as the providers.
  • If you change insurance companies, it is your responsibility to inform our staff. If you fail to do so and we file the claim with the wrong company, you could be responsible for the entire fee if the claim surpasses the filing deadline with the correct company.
  • If your insurance company does not pay the bill after repeated attempts by this office to file and obtain payment, the unpaid balance will become your responsibility. If you are able to get the insurance to pay, you will be promptly refunded minus the due coinsurance.

On Billed Statements

  • You will be getting statements in the mail
  • You have two payment options.
  1. Pay the Bill in Full within 30 days of the date posted on your statement.
  2. If you cannot pay the bill, you have 30 days to come to the office and set up a payment plan with the office staff, (first payment being due upon signing the payment agreement).
  • Failure to comply with at least one of these options will result in your account being sent to collections. You will also receive a letter that you have been released from the practice and need to find a new physician. Late balances (greater than 60 days) are subject to a 1.5% monthly interest rate, annual percentage rate of 22%. The guardian assumes all costs of collections, including, but not limited to court costs, interest, and legal fees. In this eventuality the undersigned waives venue jurisdiction and submits to the jurisdiction and venue of the State courts of Broward County.

Non-Contract Fees

Personal Care Pediatrics charges the following fees for non-insurance covered services:

Missed appointments and Cancellations with less than 24 hour notice:

Missed appointments and cancellations with less than 24 hours notice, increase the cost of medical care for everyone.  In this challenging economic time in our country we all need to work together to improve on healthcare efficiency and thereby reduce the cost for everyone and make more appointments available for everyone. Missed appointments and appointments canceled with less than 24 hour notice, work against this objective. When a family misses an appointments by failing to call to cancel 24 hours prior to the appointment  a fee of $25.00 will be charged for each missed appointment. Please note you will be considered a "No Show" if you are 30 minutes late for a scheduled appointment and you will be responsible for the fee.


Filling out medical forms takes staff time, requires medical knowledge of routine pediatric care, communicates information about your child's health, and is a legal document between our practice and other agencies. We approach these forms with the medical expertise they deserve and therefore charge the following fees for filling out medical forms for our patients. Forms can only be filled out if your child has had a well child visit within the period of time specified by the American Academy of Pediatrics. Some forms do require a hearing and vision exam to be performed and if was not done at your last well visit, the child will have to come into the office to have this done.

Forms can be given to you at the time of visit if requested otherwise there is a 24-48 hours turn around time. 

Form Price
Blue /DH 680 $5.00
Yellow/ DH 3040 $5.00
Blue and Yellow $5.00 per set
WIC $0.00
FHSAA/Sports Form $25.00
Camp Forms $5.00 - 10.00
FMLA $25.00
College Forms $10.00- 25.00

**If you need another copy of Sports or College form to be filled out there is a $5.00 fee, you will not have to pay the $25.00 again.

Record Requests

We charge $10.00 to prepare a patient's records for release to another physician or to you. This fee covers the reviewing of the medical information requested and the actual printing and mailing of the documents. We cannot begin this process until the monies are collected.

We do not charge if an insurance company requests information on the patient's chart if the insurance company was the insurer for the dates they are requesting information. However, if an insurance company is requesting records on dates of service for which they were not the insurer, a fee will be charged depending upon the number of pages requested. All requests for documents by lawyers, life insurance companies, and family mediators will be assessed a fee depending upon the number of pages requested.  All fees must be collected before the record request is initiated.

Immunization records will be faxed immediately from receipt of release and the rest of the records will be mailed out within 2 weeks of request.

Our Location

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Hours of Operation

Our Regular Schedule

Closed for lunch from: Noon-1:30pm


8:30 am-6:30 pm


8:30 am-6:30 pm


8:30 am-6:30 pm


8:30 am-6:30 pm


8:30 am-4:30 pm


8:00 am-12:00 pm