Our Financial and Office Policies

Thank you for choosing Warren Pediatric Associates as your healthcare provider. We are committed to providing our patients with the best available medical care. Our billing department will be available to discuss our fees and policies with you if you have any questions. We ask that all responsible parties read and sign our financial and office policies form and complete the patient contact form prior to seeing the physician.


All co-pays, deductibles/coinsurances or charges for non-covered services will be collected at the time of check in.  If you have a balance on your account we will ask for that payment as well. For your convenience, we accept cash, check, Visa, and Discover.  We allow 120 days for payment of any balances that are the responsibility of the patient. If we do not receive full payment in 120 days, the account will be referred to a collection agency. Interest and collection fees may be added to any unpaid balances. We understand that temporary financial problems may affect timely payments of your balance. We encourage you to communicate any such problems to us, so that we may assist you to keep your account in good standing. Any personal check returned for insufficient funds, will be charged $30.00 in addition to the amount of the check. After one instance of a returned check, all further payments will be required to be in the form of credit card, cash or money order only.

Insurance Information

Please ensure that all personal and insurance information is correct at the time of each visit. We will only bill the insurance company we have on file. Please inform the receptionist if your address, phone number, or insurance information has changed (or if you anticipate that it will be changing in the near future).

We verify insurance benefits as a courtesy to our patients. Not all services are covered benefits in your medical plan. Please contact your insurance company if you have questions regarding your health care coverage. Warren Pediatric Associates provides services that are medically necessary in the physician's professional opinion. If you are unsure if a procedure, immunization or injection is covered, please call your insurance company prior to receiving services. You are ultimately responsible for all charges that are not covered under your health care policy.  If your insurance company pays only a portion of a bill or rejects your claim, any contact or explanation should be made to you, the policy holder. Reduction or rejection of any claim by your insurance company does not relieve you of your financial obligation. In the event that your insurance company pays us for a claim that you had already paid and you are due a refund, we will be happy to expedite your refund or credit your account.  I understand that my services will be billed to my insurance company(s) provided I have given proof of my insurance coverage at the time services are rendered.  If I do not have proof of insurance coverage, I understand that payment is due at the time of service.   


Appointments not canceled with a 24 hour notice and any "no show" appointments may be subject to a no show charge. Please note that this fee is not covered by your insurance company. We sincerely hope that we will not need to collect this fee.  Rather, it is offered as an incentive to remind all of our patients and families to keep their scheduled appointments or, if unable to keep that appointment, to please reschedule at least 24 hours in advance. When you reschedule your appointment ahead of time, we are able to provide care to other patients in that time slot.  

After 3 "no show" appointments we reserve the right to terminate the physician/patient relationship. A notification will be sent to the responsible party. If you are more than 15 minutes late for your appointment, we will have to reschedule your appointment to a more convenient time.

Medical Records

When you request a copy of medical records, the patient, parent or guardian must complete an authorization for release of protected health information form before the records will be released. We require 3 day's notice to fulfill medical record requests.

Prescription Refills

MOST prescription refills can be called directly to your pharmacy. For your convenience, we transmit e-prescriptions via a secured internet network directly to participating pharmacies. You can have your pharmacy submit the refill request electronically or they may fax the request. You may request refills by calling our office or through our patient portal. Please do not wait until you are out of medication to ask your pharmacy for a refill. We require 2 business days to respond to a refill request. Please note that we do not process refill requests on the weekends or holidays. The patient must have a follow-up appointment scheduled or have been seen within the last year in order to have any prescriptions refilled.

Notice of Privacy Practices

I hereby consent to the use and disclosure of information in my medical records for treatment, payment and health care operational purposes.  I understand that information in my medical records may be used and disclosed to persons other that Warren Pediatric Associates to carry out their responsibilities with my medical/healthcare treatment.  I understand that I may request Warren Pediatric Associates to restrict to whom my medical records are used or disclosed, but that Warren Pediatric Associates may refuse the restrictions I request.  I further understand that if there are any individuals to whom patient information may not be released, but who, under law, may otherwise be entitled to receive such information (parent whom the Court has determined is not to share legal custody of a minor) I must provide Warren Pediatric Associates with a listing of the person's name and last known address in addition to the relevant legal documentation affording me the right to exclude them from receiving medical records of the treated individual or such information may not be withheld.

I understand that additional information on Warren Pediatric Associates' privacy practices related to my medical records is available from the Warren Pediatric Associates comprehensive Notice of Privacy Practices, a copy of which has been made available to me, and which I have read or do not wish to read, prior to signing this consent.  My signature below acknowledges receipt of the Notice of Privacy Practices.

Patient Portal

I acknowledge that I have read and fully understand the Patient Portal User Agreement.  I have been given risks and benefits of the patient portal and agree that I understand the risks associated with online communications between my physician and myself, and consent to the conditions outlined in the user agreement.  I understand that emergent and urgent issues should be handled by calling the office directly, going to the emergency room or calling 911 should the emergency be life-threatening. The patient portal is entirely voluntary and will not impact the quality of care I receive should I decide against using the patient portal.  In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that my physician may impose for online communication.  I agree that Warren Pediatric Associates is not responsible for any claim or action arising out of my misuse of the patient portal.  I have been given an opportunity to ask questions related to this agreement and all of my questions have been answered to my satisfaction.  My signature below acknowledges receipt of our Patient Portal Information Form.

Authorization to Treat Patient

I authorize Warren Pediatric Associates to treat my child. I further authorize the release of medical information necessary for the completion of insurance forms.  I authorize payment directly to Warren Pediatric Associates for all medical and surgical benefits otherwise payable to me under the terms of my insurance.  I understand that I am financially responsible for all co-payments and any charges not paid by my insurance.  If your child is brought in by someone other than a parent/guardian, that person is responsible for making decisions regarding that visit and any labs or procedures that are ordered.  The person accompanying the child is also responsible for the co-pay. If you do not wish to have someone else bring your child to our office to be treated, it is your responsibility to inform our office. I understand that if my child's physician, or staff is directly exposed to my child's bodily fluids in any manner which may transmit human immunodeficiency virus (HPV) or hepatitis B or C viruses, that I am deemed by law to have consented to the release of these test results to the person who is exposed to my child's body fluids.

Our financial policy is subject to change without notice.