We are committed to providing you with quality care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your responsibilities as our patient. It is your responsibility to contact our office to notify us of any changes to your information.  It is also important that you realize this is a cash-based practice, and payment is due at the time of scheduling. If you do not make timely payments, you face being terminated as a patient from this practice.  You must complete and sign our Financial Policy before care is rendered.

• Payment is due at the time of scheduling. 

• We require a credit card to be kept on file prior to the initial visit. 

• All payments should be made via our secure online platform. 

• We do not accept insurance. 

• If requested, we can provide a superbill for you to submit to your insurance company for possible out of network reimbursement. If you file a claim with your insurance company, they will be able to access information about you and/or your child which may include diagnosis, severity, treatment plan and other information they deem relevant.  

• Completion of forms such as disability forms, FMLA forms, among others, requires time away from day-to-day business operations. A prepayment of $25 per form is required. Please understand that to complete the forms your medical record must be reviewed, forms completed and signed by the physician and copied into your medical record. Some of these forms can be quite complicated and tedious to complete. Please provide us with all requested pertinent information. We request that you allow 5 business days for this process.   

• We require at least 24 hours’ notice if you need to cancel or reschedule your appointment. If you do not show up for an appointment or cancel with less than 24 hours’ notice, you will be charged the full price of the appointment. Patients with 3 missed appointments may be terminated from the practice.  

• We understand that unforeseen circumstances arise, and we offer a one-time waiver of the cancellation fee per year.  

• Additional time in the appointment will be billed in 15-minute increments at the rate of $100.00 per 15 minutes.

Authorization to Store Credit Card Information

You also understand that we keep credit cards on file. By signing this document, you authorize and consent to Ravenscroft Developmental Pediatrics, PLL to keep my credit card information on file for the purpose of processing future transactions, charges or fees associated with the services provided by Ravenscroft Developmental Pediatrics, PLLC.

1. Ravenscroft Developmental Pediatrics, PLLC will securely store credit card information in a manner consistent with the Electronic Fund Transfer Act and will only use it for authorized transactions related to the services received.  

2. Removal of credit card information at any time by contacting Ravenscroft Developmental Pediatrics, PLLC in writing or through the patient portal, though will result in inability to schedule future appointments until a new card is on file.  

3. Because of HIPAA regulations and Payment Card Industry compliance, Ravenscroft Developmental Pediatrics, PLLC is under strict guidelines for protecting your privacy and will take all necessary measures to ensure the security and confidentiality of credit card information.  

4. Updates to credit card information are expected in a timely manner to ensure accurate billing.