Office Policies

Office Policy

For New Patient Registration Forms and our Billing Policy, Patient Responsibility, Insurance and more please register through our Online Portal Services.

Billing Policy

builder-room.jpg As a courtesy to you, we can send claims to your insurance company on your behalf. If you would like us to do this please fill out the rest of this form. If you will be paying for the services yourself, you do not need to fill out this form.

Requirements for us to send claims on your behalf:

  • You must assign the payments to our office so that payments will be made directly to us
  • Co-payments are always your responsibility (not the insurance company’s) and are due at the time of your appointment. If you cannot bring exact change, please be prepared to give us a credit/debit card or a check at the time of your visit.
  • If the insurance company does not pay for the service, you become responsible for the cost of the service (this applies to all insurances including Medicaid)
  • We incur a cost when we submit claims to the insurance company on your behalf; therefore if the insurance company does not reimburse us for the service after we submit the claim we will resubmit the claim only one more time.

I hereby authorize Children’s HealthCare Center (CHCC) to submit insurance claims for services rendered and I request payment be made directly to CHCC. I certify that the above information is true and correct and I authorize CHCC to release any medical information necessary to process the insurance claim. I give permission for a photocopy of this document to be used in place of my original signature.

I understand that I, my employer or the State made the choice of my insurance company(ies) and that CHCC was not consulted. I understand that I (not my insurance company) am making an appointment with CHCC and that it is my responsibility to make myself familiar with my insurance company’s rules in order to assure that they will cover the cost of the service. This includes but is not limited to obtaining referrals and authorizations. I understand that CHCC has a lot of experience working with insurance companies and that it will try to help me with these rules, but that ultimately, I am responsible to make sure the rules are met. If CHCC is unable to obtain payment from my insurance company with two attempts, I understand that the payment of the service becomes my responsibility and I will pay it.

Failure to disclose proper primary, secondary or Medicaid coverage may affect your claim payment and a $45 fee will be charged for rebilling your claim. All claims not paid by your insurance within 60 (sixty) days will be posted to the patient. CHCC reserves the right to turn over any past due balances beyond 60 (sixty) days to a collections agency and that you will be responsible for any collection costs, attorney fees and the outstanding balance.

A signature below is required at the office," I am indicating that I have read and agreed with the statement of payment authorization for CHCC. I have had the opportunity to ask questions, and they have been answered to my satisfaction. I understand that CHCC is filing an insurance claim on my behalf as a courtesy. I understand that if my insurance company denies my claim for any reason, I am responsible for any outstanding balances including all collection costs if necessary".

Children's Healthcare Center • 605 Post Office Road, Suite 102, Waldorf, MD 20602 • Phone: (301) 374-2666