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PATIENT FORMS | Tural Pediatrics
508-674-8348 turalra@aol.com

Forms

  • Patient Registration Packet
  • Payment and Office Policies
  • Medical Consent and Payment Authorization Form
No Show Policy

It is Tural Pediatrics’ mission to deliver excellent healthcare. We request that if you are unable to come to your appointment for any reason that you call and communicate this to us.  If a patient has more than 3 missed appointments without prior notification by phone then they and their siblings may be discharged from the practice.

 

Payment & Office Policies

Thank you for choosing Tural Pediatrics as your primary care provider.  Please read our payment policy and ask any questions you may have when you check-in for your visit or call the billing department prior to your visit.  You will be required to sign our policies to confirm that you understand and agree to abide by these guidelines.

Insurance

We participate with most insurance plans.  Each plan has different policies and coverage levels and it is your responsibility to know your coverage for medical services provided.  If you are uninsured, ask us about setting up a payment plan that you can afford.  We also have applications available for state assistance if you believe you qualify.  Insurance plans change, so we ask that you verify your insurance with us at each visit.  You will be asked to show your insurance card at each visit.  If your MassHealth/BMC/Neighborhood Health Plan or any state plan has lasped, please let us know.  We can help so you are not charged for the visit.  If you reapply quickly, there is a grace period to submit your claims, if not; you will be responsible for payment.

Co-payments

Please – it is your obligation to pay your co-payment at the time of service.  Due to insurance guidelines and regulations, we must collect a  co-pay for every office visit.  If you do not pay your co-pay at the time of service, you will be charged a $15.00 bill patient fee.  Please remember we accept cash, checks, MasterCard, Visa and Discover.

Non-covered services

Please be aware that some – and perhaps all – of the services provided may not be covered or may be applied to your deductible by your insurance company.  You will responsible for payment.

Claims submission

We will submit your claims to your insurance company and assist you in any way we can to help get your claims paid.  Your insurance company may need you to supply certain information directly to them.  Please do so promptly.  However, any unpaid balance is your responsibility.

Coverage changes

Please notify us if your insurance changes before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

Non-payment

We understand that these are difficult economic times.  Please talk to us about setting up a payment plan that you can afford.  Any unpaid balances may be forwarded to a collection agency.  We make every attempt to contact you by mail and phone but it is your responsibility to contact us to set up a payment plan or update insurance information.

NOTE:  Divorce has no bearing on the responsibility for medical care as it affects third parties.  Whoever brings the child is expected to pay the charges due for the service rendered that day.  Tural Pediatrics does not participate in payment disputes between parents.