Acknowledgement of Wellness Services Billing Procedures

Acknowledgement of Wellness Services Billing Procedures

I acknowledge that during my wellness visit, there may be a problem-oriented service performed by a Blue Moose Pediatric practitioner in addition to the wellness services. In this case, I understand that two separate charges may be submitted to my insurance company and that, when applicable, a co-pay/deductible/co-insurance may be required for charges generated pertaining to problem-oriented services.

Alternatively, I understand I may choose to return for a separate visit to address problem-oriented issues, at which time, my co-pay/deductible would still apply.