Forms & Policies

Financial and Billing Policy

At Mali and Mali Pediatrics, we are committed to providing high quality medical care and fostering a strong provider-patient relationship with you and your child. In support of that commitment, we are providing you with a clear statement of our office and billing policies, which are listed below. All parents or legal guardians are asked to sign the acknowledgement of the receipt of this document.

Mali and Mali Pediatrics Office and Billing Policies

Responsible Party

The "Responsible Party" is the person who is responsible for payment of services.

You will be required to fill out and sign all necessary documents as needed.

MMP will gladly submit claims to your health insurance company for the services provided. As you would expect, any charges that your insurance company doesn't pay are clearly your responsibility. We will be happy to assist you in any way we can, but you are ultimately responsible for timely payment of your account.

If the child's parents are divorced, 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 all medical bills, MMP has no authority to enforce compliance.

You will be responsible for the charges incurred by the minor children (under age 18) who come into the office unaccompanied, or in the presence of another caregiver (i.e., grandparents, baby-sitter, etc). Note: only persons authorized by parent or guardian will be able to bring child in for an appointment and will be required to show identification.

You will be responsible for charges incurred by children who have turned 18 until such time as you notify us in writing, prior to services being provided, that you no longer accept financial responsibility.

Billable Services

MMP will charge for provider services, as well as supplies, screenings and laboratory services used for the care of your children. MMP will charge for all follow-up services. The same (staff, room, supplies, provider time, etc.) are used for the follow-up visit, so the charges will be billed accordingly.

MMP will charge for all scheduled walk-in and after hour evening and weekend appointments. We will also charge for patients who are not scheduled (i.e. siblings of a scheduled patient) that the physician is asked to see. See Appointments section below.

Occasionally a patient will be scheduled for one type of service but the provider may diagnose and treat another problem in addition to the scheduled service. When appropriate, MMP will charge for the additional service. Some insurance companies will not cover both services, which may result in the responsible party owing additional co-payment, co-insurance, deductible or denial charges.

MMP 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.

MMP reserves the right to charge for missed appointments. See Appointments section below for further description.

Portion Due at Time of Service

If you have insurance coverage, all co-pays, co-insurance and deductibles are due at the time of service.

Payment in full is due from self-pay patients at the time of service, unless other arrangements have been made with the billing department.

MMP reserves the right to charge a "re-billing" fee for the amounts that are due, but not paid, at the time of service.

Method of Payment

MMP accepts cash, check (including cashier's checks and money orders. No 3rd party checks or post-dated checks),

Visa and MasterCard (credit card payments can be made via telephone).

Insurance Coverage

It is your responsibility to provide accurate insurance information to MMP at the time of service. MMP 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. MMP will not submit claims to any auto insurance carrier. Any visit that is auto accident related will be treated as self-pay. Payment is required following the self-pay policy.

It is your responsibility to verify that our provider that you chose is a participating provider under your insurance plan, prior to receiving services. If your insurance (generally a HMO) requires that you select a PCP (Primary Care Physician), you must call your insurance company prior to your office visit to select one of our physicians as your PCP. If you have an HMO and your card does not have one of our doctors listed as the primary care physician you will be responsible for payment in full at the time of service.

It is your responsibility to verify benefits under your plan. You will be responsible for all non-covered services and services considered to be over "usual, reasonable and customary."

MMP must, under federal law, accurately report services provided to your children. Your insurance company may not pay for all services received. MMP 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 exact reason for providing them.

Your signature on this policy authorizes MMP to release health information to insurance carriers when necessary for payment, and directs them to remit payment directly to MMP (assignment of benefits).


Account statements will be sent on a monthly basis for accounts that have balances owing. Statements will show both patient (private) and insurance (pending) amounts owing. Private balances are due upon receipt of monthly statement.

It is your responsibility to provide MMP with your correct address and phone number. If a statement is returned for invalid address, your account may be sent to an outside collection agency. (See dismissal section)

Payment Plan Options

When appropriate and at MMP's discretion, MMP will offer monthly payment plans to help you manage your health care cost.

Payment plan duration will be no longer than 6 months unless special arrangements are made at MMP's discretion.

Payments are due on or before the agreed upon date. If payments are late or missed your account may be sent to an outside collections agency. (See dismissal section)

Failure to follow any or all of the payment plan requirements will render the agreement null and void.

Some services may be denied on accounts with high balances until the account is released by the billing department.


Patient credit balances will first be applied to current and/or past due balances, including those which may have been written off as bad debt or sent to an outside collection agency.


Your account may be sent to collections for the following reason but are not limited to:

  • Invalid patient demographic information (address, phone, etc.) which prevents us from contacting you regarding your account.

  • Failure to provide timely and accurate insurance information.

  • Failure to pay patient balances.

  • Failure to follow thru with payment plan agreements.

  • Failure to follow through with statement discrepancies, insurance denials or any other items on your account.

  • Failure to follow through with other correspondence from MMP.

MMP makes every effort to work with you to keep your account out of collections. However, in the event that your account is sent to a collection agency, you will be responsible for the balance of the account and all collection fees. You will also be responsible for any interest, service fees, and/or legal fees that accrue while your account is in collections.

Returned Checks

We charge a $35.00 fee for a returned check. If two checks are returned for insufficient funds, we will not be able to accept personal checks.


If MMP receives notice of a filed Bankruptcy case on your account, we will make the necessary adjustments according to bankruptcy law.

At MMP's discretion any children under the guarantor that filed bankruptcy will be dismissed from the practice. See Dismissal from Practice for specifics.

Dismissal from Practice

MMP reserves the right to dismiss patients from our practice for but not limited to non-payment, excessive missed appointments, inappropriate behavior, and non-compliance. If you have an established history of non-payment on your account, you may be eligible for dismissal.

Prior to dismissal, MMP will issue a certified letter from our practice informing you of our intent to dismiss unless payment in full is made to your account. Payment in full includes your current account balance, in addition to any amounts that have been referred to an outside collections agency.

If payment is not made within the specified amount of time, a certified dismissal letter will be issued. MMP will provide URGENT CARE ONLY visits for thirty (30) days after the date of the letter to allow you time to find another health care provider for your child(ren). You will not be eligible to see any of the providers at Mali and Mali Pediatrics after the 30-day notice has expired.


We value the time we have set aside to see and treat your child. If you are not able to keep an appointment, we would appreciate 24-hour notice. If the appointment is not cancelled at least 24 hours in advance there will be a $25.00 missed appointment charge.

If you are more than 10 minutes late for your appointment, we will do our best to accommodate you. However on certain days it may be necessary to reschedule your appointment. It is particularly difficult to reschedule well visits to later in the day due to the amount of time set aside for these visits.

We strive to minimize wait time; however, emergencies do occur and will take priority over a scheduled visit. We appreciate your understanding.

On arrival, please sign your child(ren) in at the front desk and present your insurance card at every visit. Any required documentation or updates will be taken care of at this time.

Questions or Concerns

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.

MMP Billing Department staff are available from 8:30 a.m. to 4:30 p.m. Monday-Friday. You can contact them by phone at (586)323-6300
Updated: April 15,2015