Revised 02/16/2012

Thank you for choosing Utah Valley Pediatrics (UVP) to meet your child(ren)’s health care needs. We are committed to providing the best care possible and appreciate your trust. Please understand that payment of your bill is considered part of your child(ren)’s treatment. The following document is our Financial Policy. Please read it carefully; we will require that you agree to and sign this Policy prior to receiving treatment.

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Responsible Party

  1. UVP will gladly submit claims to your health insurance for the services provided. However, any charges accrued on the account are your responsibility. You will be expected to follow up on any unpaid or incorrectly paid charges, regardless of insurance coverage. We will be happy to assist you in any way we can, but you are ultimately responsible for timely payment of your account.
  2. In divorce situations, the person bringing the child into the office is the responsible party. A divorce decree is a document that involves you, your ex-spouse and the courts. Although a divorce decree may state that an ex-spouse is responsible for medical bills, UVP has no authority to enforce compliance.
  3. You will be responsible for the charges accrued by minor children (under age 18) who come into the office unaccompanied, or in the presence of another caregiver (ie. grandparents, baby-sitter, etc.).
  4. You will be responsible for charges accrued by children who have turned 18 until such time as you notify UVP in writing, prior to services being provided, that you no longer accept financial responsibility.

Billable Services

  1. UVP will charge for physician services, as well as supplies used for the care of your children.
  2. UVP will charge for all follow-up services. The same resources (staff, room, supplies, physician time, etc.) are used for the follow-up visit, so the charges will usually be the same as the initial visit.
  3. UVP will charge for all scheduled, walk-in and after hour appointments. We will also charge for patients who are not scheduled (ie. siblings of a scheduled patient) that the physician is asked to see.
  4. Occasionally a patient will be scheduled for one type of service but the physician may diagnose and treat another problem in addition to the scheduled service. When appropriate UVP will charge for the additional service. Some insurance companies will not cover both services, which may result in a denial or higher co-pay.
  5. UVP reserves the right to charge for extensive phone calls, reporting, consultation, coordination of care with other providers and/or other services provided on your child(ren)’s behalf. Your insurance may not cover these services.
  6. UVP reserves the right to charge for missed appointments when said appointment has been confirmed, including same-day appointments. These charges will not be billed to your insurance company but will be your responsibility.

Portion Due at Time of Service

  1. If you have insurance coverage, all co-pays, co-insurance and deductibles are due at the time of service.
  2. Payment in full is due from self-pay patients at the time of service. A 30% adjustment will be given when charges are paid in full on the date of service.
  3. Payment in full is due at the time of service from non-UVP patients (tourists, etc.), regardless of insurance coverage. Your insurance (if any) will receive a claim for the full amount of the service(s) and you will be reimbursed for any overpayments once your insurance has responded.
  4. Payment in full is due at the time of service from accounts with a “bankruptcy” status if we are unable to verify your insurance benefits. If we are able to verify benefits payment for any copays, deductibles and/or non-covered services will be required at the time of service.
  5. UVP reserves the right to charge a “re-billing” fee for amounts that are due, but not paid, at the time of service.

Method of Payment

UVP accepts the following types of payments:

  1. Check (including cashier’s checks and money orders. No third-party checks)
  2. Cash
  3. Visa, Mastercard, Discover and American Express credit cards
  4. Visa, Mastercard, Discover and American Express debit cards.

Insurance Coverage

  1. It is your responsibility to provide accurate insurance information to UVP at the time of service.
  2. UVP will create and submit claims to your health insurance on your behalf. However, we reserve the right to refuse insurance and collect payment in full from you (ie. out-of-state Medicaid, insurance information provided after claim filing deadlines, etc.).
  3. UVP will not submit claims directly to an auto insurance carrier. We will provide you with the claim form, and you will be responsible to submit the claim to the appropriate no-fault carrier.
  4. It is your responsibility to verify that the doctor you have chosen is a participating provider under your insurance plan, prior to receiving services.
  5. It is your responsibility to verify benefits under your plan. You will be responsible for any non-covered services and services considered to be over “usual, reasonable and customary (URC)”. You will also be responsible for amounts not paid by your insurance for any reason, unless the amounts are covered under UVP’s contractual agreement with insurance.
  6. UVP must, under federal law, accurately report the services provided to your children. Your insurance company may not pay for all services received. UVP cannot change the service or diagnosis codes (unless they were initially reported incorrectly) in order to make a service “fit” your insurance plan benefits. We must report the exact services provided and the exact reason for providing them.
  7. Your signature on this policy authorizes UVP to release health information to insurance carriers when necessary for payment, and directs them to remit payment directly to UVP (assignment of benefits).


  1. Statements (bills) will be sent on a monthly basis when our system shows a patient (private) balance owing. The statement will list all activity on the claim(s) in question (insurance payments, insurance adjustments, patient payments, etc.) and will show the remaining balance owing, per date of service.
  2. If you have a question or concern, or if you see a discrepancy on your statement, it is your responsibility to contact the Billing Office as soon as possible. If we do not hear from you we will assume the information in our system is correct and proceed accordingly.
  3. It is your responsibility to provide UVP with your correct address and phone number. If a statement is returned for an invalid address, your account may be turned over to an outside collection agency.


  1. Interest in the amount of 1.5% of your balance per month (18% APR) will accrue on accounts with private balances older than 30 days.

Payment Plan Options

  1. When appropriate and at UVP’s discretion, UVP will offer monthly payment plans to help you manage your health care costs.
  2. Payment plan duration will be no greater than 5 months unless special arrangements are made, again at UVP’s discretion.
  3. Interest will accrue on payment plan accounts, as listed above.
  4. Payments are due on or before the agreed upon date. If payments are late or missed your account may be turned over to an outside collection agency without further notice.
  5. Payment plans are intended to help bring past-due amounts current. All co-pays and deductibles are required at the time of service and will not be added to a payment plan.
  6. Failure to follow any or all of the payment plan requirements will render the agreement null and void.


  1. Any insurance credits or over-adjustments will be returned to the appropriate insurance company.
  2. Any patient credits or overpayments will first be used to pay past-due balances, including those which may have been referred to an outside collection agency.
  3. If patient balances have been resolved, patient credits will be returned to you (or the person/organization who paid). Please allow 2-3 weeks for processing. Smaller credits (generally under $20.00) may be left on the account to be used for future co-pays and/or deductibles.


  1. Your account may go to collections for the following reasons that include but are not limited to:
  2. Invalid patient demographic information (address, phone, etc.) which prevents us from contacting you regarding your account.
  3. Failure to provide timely, accurate insurance information.
  4. Failure to pay patient balances.
  5. Failure to follow through with payment plan agreements.
  6. Failure to follow through with statement discrepancies, insurance denials or any other items on your account.
  7. Failure to follow through with other correspondence from UVP.
  8. UVP makes every effort to work with you to keep your account out of collections. However, in the event that your account is referred to a third party debt-collection agency, you will be responsible for the balance of the account in addition to a 30% collection fee and any other amounts allowed by law (interest, court costs, attorney’s fees, etc.), as allowed by Utah Code Annotated section 12-1-11.

Returned Checks

  1. Checks returned unpaid by your bank, regardless of the reason, will be posted back to your account in the original amount of the check, in addition to a $15.00 return check fee. You may also be responsible for interest, costs of collection, court costs and reasonable attorney fees as allowed by law.
  2. Writing a bad check is a Class One Misdemeanor. UVP reserves the right to prosecute to the fullest extent of the law when a check is returned unpaid from the bank.


  1. If UVP receives notice of a filed Bankruptcy case on your account, we will make the necessary adjustments to your balance according to bankruptcy law.
  2. Your account will be placed in bankruptcy status. Each time you schedule an appointment the front office will transfer your call to the billing department for insurance verification.
  3. You will be required to pay in full at the time of service, unless we are able to verify coverage with your insurance at each visit. If we are unable to verify coverage (holidays, after-hours, invalid insurance, etc.), payment in full at the time of service will be required. We will be happy to submit a claim to your insurance on your behalf and, if your insurance pays on the claim, you will be refunded any overpayments.
  4. If we are able to verify insurance benefits you will be required to pay the “member portion” at the time of service, as determined by your insurance for the visit type. This may include copays, deductibles and/or non-covered services. The amount given as “member portion” at the time of service may not be the total amount you will owe once insurance processes the claim.
  5. If you are unable to pay your portion at the time of service you may be referred to an Instacare Facility or Emergency Department.
  6. Your account will remain in a bankruptcy status for two (2) years from the bankruptcy file date or from the last collection activity on your account, whichever time is shorter, until the statute of limitations on the bankruptcy expires (7 years). After such time the bankruptcy status will be removed from your account and normal payment policies will apply.

Dismissal from Practice

  1. UVP reserves the right to dismiss patients from our practice for non-payment. If you have established a history of non-payment on your account, you may be eligible for dismissal.
  2. Prior to dismissal, UVP will issue a certified letter informing you of our intent to dismiss unless payment in full is made on your account. Payment in full includes your current account balance, in addition to any amounts that have been referred to an outside collection agency.
  3. If payment is not made within the specified amount of time, a certified dismissal letter will be issued. UVP will provide EMERGENCY CARE ONLY for thirty (30) days after the date of the letter to allow you time to find another physician for your child(ren). You will not be eligible to see any of the physicians at Utah Valley Pediatrics after the 30-day notice has expired.

Questions or Concerns

  1. If you have any questions regarding your account, or need clarification on any of the items listed in this financial policy, please contact our Billing Department.
  2. UVP Billing Department Staff are available from 9:00 a.m. to 5:00 p.m. Monday through Friday. You may contact them by phone at (801) 374-8863, by e-mail or in person at the Provo North University Billing and Administration Office at 1355 North University Avenue Suite 220, Provo, UT 84604.

Thank you for trusting Utah Valley Pediatrics with the care of your children. We are dedicated to making your experience a positive one. Please do not hesitate to contact us with any questions regarding your account, payment options or financial responsibilities.

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