If your child has a
life-threatening emergency,
call 911 immediately.

Call the Main Line for
Appointments, Urgent Issues
and Triage Nurse

Fax: 952-401-8242
An EEO/AA Employer

Financial Policy

It is the commitment of this office to help keep your health care costs as low as possible. In order to do this, we need to keep our billing costs at a minimum. Please help us in the following ways: 

  • Always bring your current health insurance card to the office.
  • Please notify us immediately of any changes in insurance, address, phone #, etc.
  • Please be prepared to pay your co-pay at the time of service; or if you do not have insurance, to pay for your visit in full.
  • Please pay your bill in full when you receive your statement or make payment arrangements with the Patient Account Services department.

Late or missed payments may be reported to a credit reporting agency. Accounts may be turned over to an outside collection agency. Past due balances will be charged a collection fee as listed below based on the account balance. Parents/Guardians will be responsible for all additional fees and expenses incurred as a result of trying to collect a past due balance. Failure to resolve a collection agency balance may result in termination of care at South Lake Pediatrics. 

Account Balance Collection Fee
$.01-$250 $25
$250.01-$500 $50
$500.01+ $100
The adult accompanying a minor to a visit and/or the legal parents/guardians are responsible for full payment (regardless of insurance coverage) and will be set up as the person who receives the bill (guarantor) and must provide complete demographic information including both parents dates of birth and social security numbers, current address and telephone numbers. South Lake Pediatrics will not be involved in negotiating between parents/guardians in disputes. In order to change a guarantor, the person who will receive future bills must complete and sign a Change Of Guarantor Form.


Parents/Guardians are responsible for knowing their insurance benefits. Insurance plans vary considerably and we cannot predict or guarantee what part of our services will or will not be covered by your particular plan. The patient/parent/policyholder is responsible to know the benefits of their health plan. South Lake Pediatrics cannot change coding in an attempt to obtain payment.

  • Hearing and vision exams are often not covered as well as supplies such as crutches, slings, and braces. 
  • Mental Health benefits are often different than medical benefits.  Common conditions such as ADD, ADHD, Developmental Delays, Learning Disorders, Depression, Autism, Anxiety, and others are usually considered under the mental health benefits of an insurance plan.  This is especially true for Psychological Testing. 

Throat culture only and/or Strep test is considered a nurse visit and an office visit charge will apply in addition to the charge of the lab test(s).

During a periodic health exam additional tests or procedures may be ordered such as hearing and vision screening, immunizations and laboratory tests.  These are each separately charged.  According to AMA guidelines, when a patient presents for a periodic health exam with concerns that require evaluation beyond the scope of a routine periodic health examination, the coding must be adjusted to reflect the additional services performed.  The coding used to report these services is not covered by insurance carriers as a periodic health exam.  These services are subject to any copay, deductible, or policy restriction that may exist.  Further definitions of these criteria may be discussed with your physician or nurse practitioner.

A clear understanding of our financial policy is an important part of our professional relationship.  We are pleased to discuss the financial aspect of your care.  Feel free to contact our Patient Account Services department for questions regarding fees, financial responsibilities, or our Financial Policy.

Additional Policies

X-Ray & Reference Laboratory Services
I understand that if my child receives an x-ray as part of his/her diagnosis or treatment, the x-ray will be reviewed by an outside radiologist. I understand that blood and other specimens may be sent to an outside laboratory for testing. I further understand that the radiologist and reference laboratory will bill separately for their services. I consent to South Lake Pediatrics supplying the radiologist and/or the reference lab with my demographic information as necessary for billing purposes.
Non-Violence Philosophy
South Lake Pediatrics recognizes that it is in the best interest of the community, employees, customers and the organization as a whole to maintain an environment which is free from violence and harassment. Threats, harassment, aggressive or violent behavior by employees, patients, parents, visitors or others will not be tolerated. South Lake Pediatrics will hold all individuals responsible for the effect their behavior has on the clinic.
Cancellation of Appointments
I understand that I must give the clinic a 24 hour notice of any canceled appointments. If I fail to keep my scheduled appointments, I may be at risk of not receiving future services.

February 28, 2014