Office Policies

 Financial Policy of Pediatric Health Associates, Ltd. 

Our professional staff is committed to providing you with quality pediatric care and our business office is committed to assisting you with the financial obligations of your medical care.

Pediatric Health Associates firmly believes that a good physician/ patient relationship is based upon understanding and good communication.  Therefore, we have outlined our financial policy so that patients will better understand the billing process and their responsibility in it.

Pediatric Health Associates, Ltd will:

1. File primary & secondary insurance claims on your behalf in a timely manner.
   
2. Seek information to process claims and answer questions about the claims.
   
3. Issue statements to you once insurance has made payment for services.
   
4. Accept payment by cash, check and most major credit cards
   
5. Arrange payment plans when necessary

Your responsibilities will be to:

1. Complete our patient information form and supply any insurance information that is necessary to process your claims.
   
2. Notify us of any changes in your insurance status or insurance company.
   
3. Pay your copay at the time of service.  If you cannot pay your copay by 11:00pm on the date of service a $15.00 fee may be charged to you.
   
4. Pay any outstanding balance which is unpaid, denied or delayed by your insurance carrier beyond 30 days after the date of service.  Pediatric Health Associates does not get involved in financial, legal, separation, or divorce disputes.  Therefore, if the guarantor is delinquent in paying the account, the balance will be transferred to the person who registered the child at the time of service.  If a divorce decree or such requires the other parent to pay all or part of the treatment costs, it is the registering party’s responsibility to pay the balance and collect from the other parent.
   
5. Call your insurance carrier, at our request, to expedite payment for delayed claims.
   
6. Call your insurance carrier when a submitted claim was denied.  Denied and disputed claims do not suspend your requirement to pay for services rendered.
   
7. Be responsible for deductibles or uncovered expenses.  This may include charges for screening forms that are required or recommended by the American Academy of Pediatrics.  Patients seen for a well visit may incur additional charges for services, such as counseling for immunizations, risk factor reduction intervention, procedures or any new or ongoing problem that is addressed.
   
8. Pay a $30.00 fee per check returned to us by the bank for non-sufficient funds (NSF).
   
9. Authorize Pediatric Health Associates to provide your insurance carrier with any clinical information they may require.
   
10. Pay in full for office visit at the time of service if no current insurance card is presented.
    
11. Inform us of any appointments you need to reschedule or cancel.  You may be charged a $40.00 fee for sick and recheck appointments and $50.00 for well visits not cancelled at least 24 hours in advance of appointment time.
    
12. We will do our best to resolve insurance issues and will enlist your help when necessary.  Your insurance is a contract between you and your insurance carrier.  Therefore, you will be more likely to get the carrier to meet their financial obligation when they delay payment on your claims.  Please remember that we file insurance as a courtesy to you.  You, not the insurance carrier, are ultimately responsible for any unpaid fees.

The Immunization Data Registry Act, 410 ILCS 527, authorizes the Illinois Department of Public Health (IDPH) to develop and maintain an immunization data registry to collect, store, analyze, release and report immunization data. Accordingly, IDPH has established the Illinois Comprehensive Automated Immunization Registry Exchange (I-CARE Registry). Protecting the privacy of clients and the security of the data contained in the I-CARE Registry is a high priority for IDPH.

The information contained in the I-CARE Registry shall only be used for the following purposes:

1. To provide immunization services to the client, including reminder/recall notices.
   
2. Permit schools to determine the individual immunization status of their students.
   
3. Eliminate the administration of duplicate immunizations.
   
4. To provide or facilitate third party payments for immunizations, e.g., medical assistance.
   
5. To assess immunization coverage rates.
   
6. To accomplish other public health purposes as determined by IDPH.

* What this means is that your child’s immunization data will be electronically transmitted to the I-Care registry whenever immunizations are administered in our office.

 Who can access this information? 

Health Care providers, local Health Department, elementary or secondary schools, licensed child care centers, licensed child-placing agencies, College or University Illino is Department of Public Health employees and their authorized agents.

Should you choose not to participate in the I-CARE Registry, you may opt out by signing the “opt out” registry form available in our office. You may obtain one simply by requesting it at the front desk.

*Illinois Department of Public Health - Version 07.25.12

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This practice creates a medical record of your health information in order to treat you, receive payment for services delivered, and to comply with certain policies and laws. We are also required by law to provide you with this Notice of our legal duties and privacy practices. In addition, the law requires us to ask you to sign an Acknowledgment that you received this Notice.

We are required by federal and state law to maintain the privacy of your medical information. Medical information is also called “protected health information” or “PHI.”  We are also required by law to notify you if you are affected by a breach of your unsecured PHI.

This is a list of some of the types of uses and disclosures of PHI that may occur:

Treatment:  We obtain health information, or PHI, about you to treat you. Your PHI is used by us and others to treat you. We may also send your PHI to another physician, facility, or counselor to which we refer you for treatment, care, procedures, or testing. We may also use your PHI to contact you to tell you about alternative treatments, or other health-related benefits we offer. If you have a friend or family member involved in your care, we may give them PHI about you.

Payment: We use your PHI to obtain payment for the services that we render. For example, we send PHI to your insurance plan to obtain payment for our services.

Health Care Operations: We use your PHI for our operations. For example, we may use your PHI in determining whether we are giving adequate treatment to our patients. From time-to-time, we may use your PHI to contact you to remind you of an appointment.

Legal Requirements:  We may use and disclose your PHI as required or authorized by law. For example, we may use or disclose your PHI for the following reasons:

Public Health: We may disclose your health information to prevent or control disease, injury or disability, to report births and deaths, to report reactions to medicines or medical devices or to report suspected cases of abuse or neglect.

Health Oversight Activities: We may use and disclose your PHI to state agencies and federal government authorities when required to do so. We may use and disclose your health information in order to assist others in determining your eligibility for public benefit programs and to coordinate delivery of those programs. For example, we must give PHI to the Secretary of Health and Human Services in an investigation into our compliance with the federal privacy rule.

Judicial and Administrative Proceedings: We may use and disclose your PHI in judicial and administrative proceedings. Efforts may be made to contact you prior to a disclosure of your PHI to the party seeking the information.

Law Enforcement: We may use and disclose your PHI in order to comply with requests pursuant to a court order, warrant, subpoena, summons, or similar process. We may use and disclose PHI to locate someone who is missing, to identify a crime victim, to report a death, to report criminal activity at our offices, or in an emergency.

Avert a Serious Threat to Health or Safety: We may use or disclose your PHI to stop you or someone else from getting hurt.

Work-Related Injuries: We may use or disclose PHI to an employer if the employer is conducting medical workplace surveillance or to evaluate work-related injuries. 

Coroners, Medical Examiners, and Funeral Directors: We may use or disclose PHI to a coroner or medical examiner in some situations. For example, PHI may be needed to identify a deceased person or determine a cause of death. Funeral directors may need PHI to carry out their duties.

Armed Forces: We may use or disclose the PHI of Armed Forces personnel to the military for proper execution of a military mission. We may also use and disclose PHI to the Department of Veterans Affairs to determine eligibility for benefits.

National Security and Intelligence: We may use or disclose PHI to maintain the safety of the President or other protected officials. We may use or disclose PHI for the conduct of national intelligence activities.

Correctional Institutions and Custodial Situations: We may use or disclose PHI to correctional institutions or law enforcement custodians for the safety of individuals at the correctional institution, those that are responsible for transporting inmates, and others.

Research: If the practice participates in research, we may use or disclose your patient information without your authorization if an Institutional Review Board approves a waiver of authorization.  If a waiver has not been approved, we will obtain your written authorization as required by law before your health information is used for research.

Fundraising:  We do not engage in fundraising activities. We do not engage in marketing activities, and need your authorization to do so.

Immunizations: If we obtain and document your verbal or written agreement to do so, we may release proof of immunization to a school where you are a student or prospective student.

Autodial and Electronic Contact:  I authorize you, your affiliates, business associates and agents to contact me at the telephone numbers I have provided you.  Contact may be by using autodialed calls, text messages, and artificial voices or prerecorded voices, for purposes of your healthcare operations, billing, collections and other account activities, patient surveys, and marketing.  I understand that I am not required to provide this call authorization and it is not a condition to receiving healthcare services.  I may revoke this call authorization at any time by notice to you.

Illinois law:  Illinois law also has certain requirements that govern the use or disclosure of your PHI. In order for us to release information about mental health treatment, genetic information, your AIDS/HIV status, and alcohol or drug abuse treatment, you will be required to sign an Authorization form unless state law allows us to make the specific type of use or disclosure without your authorization. 

Your Rights:  You have certain rights under federal and state laws relating to your PHI. Some of these rights are described below:

Restrictions: You have a right to request restrictions on how your PHI is used for purposes of treatment, payment and health care operations. We are not required to accommodate to your request, except as required by law. The practice is required to comply with your request for restrictions on the use or disclosure of your PHI to health plans for payment or health care operations purposes when the practice has been paid out of pocket in full and the practice has been notified of the request for restriction in writing, and the disclosure is not required by law. 

Communications: You have a right to receive confidential communications about your PHI. For example, you may request that we only call you at home. If your request is reasonable, it may be accepted. 

Inspect and Access: You have a right to inspect your health information. This information includes billing and medical record information. You may not inspect your record in some cases. If your request to inspect your record is denied, we will send you a letter letting you know why and explaining your options. 

You may have a paper or electronic copy of your PHI in most situations. If you request a copy of your PHI, we may charge you a fee for making the copies and mailing them to you, if you ask us to mail them.
 
Amendments of Your Records: If you believe there is an error in your PHI, you have a right to request that we amend your PHI. We are not required to agree with your request to amend.

Accounting of Disclosures: You have a right to receive an accounting of disclosures that we have made of your PHI for purposes other than treatment, payment, and health care operations, or release made pursuant to your authorization.

Copy of Notice: You have a right to obtain a paper copy of this Notice, even if you originally received the Notice electronically. We have also posted this Notice at our offices.

Complaints:  If you feel that your privacy rights have been violated, you may file a complaint with our office. We will not retaliate against you for filing a complaint. You may also file a complaint with the Secretary of Health and Human Services in Washington, DC if you feel your privacy rights have been violated.

Authorizations: We are required to obtain your written Authorization when we use or disclose your PHI in ways not described in this Notice or when we use or disclose your PHI as follows: for marketing purposes, for the sale of your PHI, or for uses and disclosures of psychotherapy notes (except certain uses and disclosures for treatment, payment, or health care operations), You may revoke your Authorization at any time in writing, except to the extent that we have already acted on your Authorization.

 Your health information is kept in an electronic format. A Health Information Exchange allows health care providers to access clinical information about patients from other treating facilities. The practice participates in two health information exchanges: the Community Connect Health Information Exchange operated by Ann & Robert H. Lurie Children’s Hospital of Chicago (the “Exchange”), andCareEverywhere®. 
 

• Community Connect Health Information Exchange.  We, along with certain other health care providers and practice groups in the area, participate in a health information exchange operated by Ann & Robert H. Lurie Children’s Hospital of Chicago (“Lurie Children’s”). The Exchange facilitates the electronic sharing and exchange of medical and other individually identifiable health information regarding patients among health care providers that participate in the Exchange, including Lurie Children’s Affiliates. Through the Exchange, we may electronically disclose demographic information including cellular phone numbers and/or email addresses you provide, and medical, billing, and other health-related information about you to other health care providers that participate in the Exchange and request such information for purposes including but not limited to facilitating or providing treatment, arranging for payment for health care services, or otherwise conducting or administering their health care operations.
• CareEverywhere®. We have a software product called CareEverywhere® that allows us to exchange health information with other providers that have the CareEverywhere® product. The CareEverywhere® exchange facilitates the electronic sharing and exchange of medical and other individually identifiable health information regarding patients among health care providers also have the CareEverywhere® software. Through the software CareEverywhere®, we may electronically disclose demographic, medical, billing, and other health-related information about you to other health care providers that participate in the Exchange and request such information for the purposes including but not limited to facilitating or providing treatment, arranging for payment for health care services, or otherwise conducting or administering their health care operations. Due to our participation in the Exchange, your electronic health information from our practice may be made available to other providers through Lurie Children's shared electronic medical record.

 
 You may opt out of participation in the exchanges described above at any time by contacting the practice. Health information that has already been shared cannot be revoked. However, if you do not consent to sharing health information for treatment purposes in the health exchanges described above, your health information will not be stored in an electronic health record. Hardcopy (paper) health records may not be immediately available or transmittable to your other health care providers for treatment purposes, including in emergency situations.

Illinois Immunization Registry: We may disclose information concerning your immunization records to the Illinois Department of Public Health (“IDPH”) for inclusion in a centralized database of children’s immunization records. Such information may be used by IDPH, public vaccine providers, community health centers, the Centers for Disease Control and Prevention, or any other person or entity providing immunization services or approved by IDPH as needing to know your health or immunization status. Such information may be used by these recipients to: provide immunization services to you; monitor your immunization status; promote adherence to recommended immunization schedules; assist in the preparation of vaccination documentation required by your school; prepare statistical reports on immunization status of groups of patients in which neither you nor any other patient may be individually identified; and otherwise monitor and promote your health and the health of children in Illinois generally. You have the right to opt out of participating in this registry.

You may opt out of certain provisions of the Notice, as indicated herein, by providing separate written notice.  We are required to abide with terms of the Notice currently in effect, however, we may change this Notice.  If we materially change this Notice, you can get a revised Notice at our office or on our practice website.  Changes to the Notice are applicable to the health information we already have.

 
 Parent/Guardian Signature for patient under 18 years of age:               Date:
 _____________________________________________     __________________

 Lurie Children's Community Connect Document - Revised July 2017

Vaccine Policy
 

PHA: What to Expect at Well Visits
At Pediatric Health Associates, we follow the recommendations of the American Academy of Pediatrics and the Center for Disease Control and require all patients be vaccinated. Failure to vaccinate your child within 4 months of the first visit will be reason for removal from the practice. We require that the child receives at least 2 injectable vaccines and an oral vaccine at each visit where immunizations are needed. Patients must be immunized with MMR by 15 months.

*Beyfortus: Recommended once during RSV season (Sept-Mar) for all infants <8 months old
Flu and COVID-19 vaccines: Recommended annually for all patients 6 months+
Fluoride: Recommended for patients 9 months-36 months (may vary slightly)

 

Combination Vaccine
Vaxelis (DtaP-IPV-Hib-Hep B)                     Pentacel (DtaP-IPV-Hib)
Quadracel (DTaP-IPV)                                  ProQuad (MMR-Varicella)

Updated 4/2025

I authorize Pediatric Health Associates, Ltd. to release any medical information and copies of any medical records necessary to process a related claim and to request payment of benefits directly to Pediatric Health Associates, Ltd.

I also authorize Pediatric Health Associates, Ltd. to release to my current and former insurance plans and any other treating or consulting physicians, other health care professionals, laboratories, and healthcare facilities, any medical information and copies of any medical records requested by those parties for purposes including but not restricted to:

• Medical consultations and office visits
• Hospitalizations
• Lab/medical testing
• Insurance chart reviews

I also understand that de-identified patient information may be given to researchers that we are working with. Medical information will only be released to the parents/legal guardian of patients 17 years of age and under and directly to patients 18 years of age and older. Medical information will not be released to any other parties, unless legal documentation has been provided to Pediatric Health Associates, Ltd.

Date of Service: ____________________________ For Office Use Only: MRN#: _______________

This notice will provide you with information regarding your responsibility for payment of today’s visit.

If you have:

• No insurance
• Commercial insurance with a carrier that PHA is not contracted with
• Or STATE insurance with limited benefits

Payment will be collected for the well checkup or office visit portion prior to your visit with the Doctor or Nurse Practitioner, as we do not know what additional services may be provided during the appointment for each child. Please see the receptionist following your appointment to pay for additional services that may be provided which can include, but are not limited to vaccines, labs, screening forms or you will receive a bill in the mail. We accept cash, check, Discover, Visa, MasterCard, and American Express.

If your visit is a result of a car accident or workman’s compensation injury, we will submit your claim to your health insurance carrier we have on file. We will advise you of the determination of the claim and supply you with a Health Insurance Claim Form if there is a balance due to submit to your auto carrier or your employer for further processing. You will be responsible for payment on the claim balance within 30 days of this determination.

If you have commercial insurance that PHA is contracted with, but we are unable to verify coverage, payment will be expected at the time of service as stated above. You have 30 days from the date of service to provide our office with a copy of your insurance card and we will submit your claim for payment. Please note that we are unable to submit HMO claims that do not have our Site number and PCP assigned.

Your signature is required for today’s visit acknowledging your understanding.

Patient Name: ______________________________________________
Date of Birth: __________________________ Guarantor Name: __________________________________ Guarantor Signature: _______________________________
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Patients with YouthCare insurance

PHA may bill members for services NOT covered by YouthCare or for applicable copayments, deductibles or coinsurance as defined by the state of Illinois.

I understand that, in the opinion of PHA, the services that I have requested to be provided to the patient may not be covered under the Integrated Care Program as being reasonable and medically necessary for patient’s care. I understand that YouthCare through its contact with the Illinois Department of Healthcare and Family Services determines the medical necessity of the services that I requested for patient to receive.

I also understand that I’m responsible for payment of the services I requested for patient to receive if these services are determined not to be reasonable and medically necessary for patient’s care.

Patient Name: _______________________________________________
Date of Birth: __________________________ Guarantor Name: __________________________________ Guarantor Signature: _______________________________

We ask that you please arrive on time to your scheduled appointments. We understand that things happen that may be beyond your control, however, we reserve the right to reschedule your appointment if you arrive more than 15 minutes late.



Effective January 24, 2022, PHA requires at least 24 hours’ notice in advance from your scheduled appointment time to cancel or reschedule. We reserve the right to charge a fee, $50 for checkups and sports physicals and $40 for all other appointments if you fail to notify the office in a timely manner. You will be responsible to pay this fee, as it is not billable to insurance. Multiple missed appointments per family or failure to follow our policy, may result in dismissal from the practice.

All patients under the age of 18 MUST be accompanied by a parent/legal guardian to a well exam visit. Patient will not receive any vaccinations if parent/legal guardian is not present.

 Póliza Chequeo Físico 

Un padre/tutor legal DEBE de estar presente en el chequeo físico de los pacientes menores de 18 años. El paciente no recibirá ninguna vacuna si padre/tutor legal no está presente.