forms & policies

FORMS/POLICIES

Notice of Privacy Practices (HIPPA)

Patient Financial Policy

Good Faith Estimate Notice

Divorced/Separated Parents Policy

Missed Appointment/No Show Policy

Paperwork/Medical Record Request Policy

Medication Refill Policy

Patient Portal Policy

New Patient Application

IHSAA Physical Form

Release of Records

BILLING

Full payment for all copays, deductibles, and non-covered services are expected at the time of service. All services will be billed to your insurance and any remaining balance is the responsibility of the account guarantor.

Copays are expected at check-in and may not be added to payment plans. We accept cash, checks, debit, credit (Mastercard, Visa, and Discover), and HSA for your convenience.

We are only able to bill the person listed as the guarantor on your child’s account. We cannot be responsible for any other reimbursement arrangements made between parents or other individuals.

Checks returned to our office for insufficient funds will result in a $40.00 fee being charged to your account.

INSURANCE

We participate with most major insurance companies, including some Indiana Medicaid plans (Verida, Hoosier Healthwise-Mdwise, & Hoosier Care Connect-MHS); however, each company offers many different plans and Northside Pediatrics may not be in network.

We recommend that you contact your insurance company prior to making an appointment to verify:

  • we are a participating provider on your specific plan.

  • if your plan requires you to select a Primary Care Physician (PCP). If so, verify your Northside Pediatric Physician is the assigned PCP.

  • your co-payment for primary care.

  • if you have a deductible and request an estimate regarding your out-of-pocket costs for the office visit.

QUESTIONS?

Please contact our Billing Department at (812) 379-9524 x 106

For full billing and insurance policy details, please refer to our Financial Policy.