Financial Agreement

Financial Agreement between Gold Pediatrics LLC and the Guarantor:

In return for services provided by Gold Pediatrics LLC we expect payment, at the time the service is rendered. Our practice is a participant with many health insurance companies. We recommend that you verify our participation with your insurance plan as financial responsibility ultimately belongs to the Guarantor of each account.

Your insurance policy is a contract between you and your insurance company. It is your responsibility to know and understand the provisions of benefits and payment for services rendered at Gold Pediatrics LLC. Please be aware of any co-payments, deductibles and/or co-insurances due at time of services rendered.

Financial Responsibility:

The Guarantor for the child(ren)’s account is responsible for all co-payment, co-insurance, and deductible amounts. Additionally, the guarantor is responsible for all charges and supplies that are not covered by the insurance company. Payment will be collected at the time of service for any known account balance in addition to any co-payment amount. Acceptable forms of payment include credit card, cash, or check. Return checks are subject to the return check fee of $35: The account will be charged for this amount on top of the original amount of the bill. After one returned check, we will no longer accept personal checks on your account.

Co-payments, Deductible, and Co-insurance:

Co-payments, deductibles, and co-insurance amounts are a contractual agreement between the Guarantor and their insurance company. As these are contractual agreements, co-payments and deductibles are due at the time services are rendered. If you have a deductible, the following payment terms apply: $65 deductible deposit for office visit, and $85 for preventative care office visit, are due for each visit, and each child, until your deductible has been met.

Our office will attempt to verify your deductible balance prior to every visit. As with any verification the dollar amount quoted to us may not reflect your actual deductible balance. However, we will collect the deductible deposit, and/or co-payment amount based on the information provided to our office at the present time.

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8:00 am-5:00 pm


8:00 am-5:00 pm


8:00 am-5:00 pm


8:00 am-5:00 pm


8:00 am-5:00 pm


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