Edgewood Center Pediatrics, P.C.
8896 Commerce Rd, Suite 5
Commerce Township, MI 48382
Ph - 248-360-9241
Fax - 248-360-0830

Financial Agreement

  • Payment is due at the time of service. All medications, copays, deductibles, and non-covered services must be paid in full at the time of service. Please be aware of your co-pay!
  • The parent or guardian who signs our acknowledgement, authorization, and office policy forms will be the listed guarantor on the patient's account.
  • Your insurance is a contract between you, your employer, and the insurance company. We are not party to the contract. Not all services are covered. It is your responsibility to understand your coverage and benefits including waiting period time frames, preventative care limits and maximums, including immunizations, labs, physicals, deductibles, and co-pays.
  • We bill Medicaid and Medicaid HMO Plans as Primary Insurance ONLY.
  • We are unable to guarantee what your insurance will or will not pay. We will work hard to assist you in receiving the maximum benefits available under your policy
  • We will assist you with your insurance plan requirements, for referral, pre-certifications, or authorization to see another doctor or specialist other than your PCP. However, once requested, we require 5-7 business days to fulfill such requests. (HMO & EPO plans only)
  • We realize that temporary financial problems may affect timely payment on your account. If such problems arise, we encourage you to contact our billing department for assistance in the management of your account. If you have not contacted us or paid on your balance for 90 days, your account will be reviewed for the collection agency process.
  • Edgewood Center Pediatrics bills code 99051 to your insurance company. After 5:00pm office visit appointments and Saturday/Sunday and holiday office visits will be charged an additional $25.00 fee. This fee may or may not be covered by your insurance company.
  • New baby(s) to the practice MUST be added to insurance by their 1-month checkup to avoid any fees from visits during the first 30 days from birth date. If the child/patient is not added to insurance by 2-months of age, the responsible party will be billed for any balance that has accrued
  • There will be a $35.00 no show fee for physical/well visit appointments, consult appointments, COPE and medication follow-up appointments. You have a 24hr cancelation period, to cancel your appointment. If there are multiple no- shows, our practice may terminate its relationship with you.
  • There will be a $25.00 fee for any returned checks for non-sufficient funds.
  • Our providers make every attempt to stay up to date with insurance requirements but most importantly focus on the medical care of their patients. The physicians are not experts on insurance and cannot be aware of all financial arrangements. Please feel free to discuss any insurance or financial issues or concerns with the office manager/billing department prior to services being rendered.

I, the undersigned, accept and agree to the above stated terms of the Financial Agreement.