Payment Policy

Village Pediatrics of Chapel Hill Patient Payment Policy

Revised: January 2020

Thank you for choosing our practice! We believe that establishing a written financial policy is mutually beneficial for all parties. It is our goal to avoid any miscommunication or concerns regarding financial matters in order to focus our energies on providing healthcare services to our patients.


  • Please provide a copy of your insurance card at each visit.
  • We participate with most insurance plans. Your insurance coverage and benefits are a contract between you and your insurance company. Each plan has different benefits as well as different financial obligations. Not all insurance policies cover all services. It is your responsibility to check your insurance company to determine covered benefits.
  • We are required to file with your primary carrier only. It is your responsibility to file charges with any secondary insurance carries for reimbursement.
  • If you have insurance coverage under a plan with which we do not have a contract, you will be treated as a “self-pay” patient and will be provided documentation to assist you in filing your own claim. We offer a reasonable discount for our cash paying patients. We will give you an estimate of what will be due at the time of service and payment for services is due at the time of service. You will be asked to sign a waiver stating that you have no health insurance and will not be filling with any health insurance carriers. Failure to sign this waiver may result in cancelation of your appointment. 
  • We cannot extend professional courtesy discounts.


Payment is expected at the time of service. This includes co-pays, co-insurance, balances, and deductibles.  Failure to produce payment at check-in may result in you appointment being rescheduled.  

  • As a courtesy to our patients we gladly accept cash, check, money-order, Visa, MasterCard, American Express and Discover.
  • Yearly deductible plans: Families who must meet yearly deductibles will be required to pay $75.00 at the time of service. A claim will be generated to your insurance company so that this amount will be credited to your deductible. In addition, we require a copy of your health savings account debit/credit card or a personal debit or credit card to remain on file in our office. Your card will be charged and a receipt generated once your insurance company send us your explanation of benefits for the claim. If there has been an overpayment, we will issue you a refund check the following business day. If you do not place a credit card on file, payment in full is required on the date of service and a refund will be issued once your insurance company processes the claim.
  • In the case of services provided to minors, the individual who initiates services for the child will be responsible for payment. We do not bill another individual or estranged spouse for payment.
  • A service charge of $35.00 will be added for:
    • Returned checks
    • Re-filing of insurance due to incomplete or incorrect information given at the time of service.
    • Administrative fee associated with accounts turned over to collection agencies.


  • Any amount not covered by the insured/patient’s insurance is due within 30 days of the time of service. Late payments will incur an additional $10.00 per month billing fee.
  • Balances on account must be paid prior to receiving additional services.
  • No balance over $500.00 can be carried on a family account.
  • Accounts will be turned over to a collection agency if past due 90 days or more. The patient family will be responsible for all collection costs involved with the collection of this account including court cost, reasonable attorney fees and all other expenses incurred with collection if there is a default on any unpaid balance.
  • Failure to pay balance may result in discharge from the practice. 
  • Should you have extraordinary financial pressures, we will assist you with a payment plan, agreed to in writing with our billing department prior to services being rendered.


Appointments and Canceling Services

  • An appointment written in our schedule with your child’s name on it is a bond of trust that we will be here to serve you and you will be present for that appointment. The appointment is made with your approval and is considered confirmed whether or not you have received an e-mail or call reminder. On the occasion that we might run late, it is due to attending to unanticipated needs of other patients, just as your unanticipated needs might require attention.
  • We require 24 hours’ notice to cancel pre-scheduled appointments and 2 hours’ notice to cancel a same day appointment. We charge a $75.00 no-show fee for missed appointments, pre-scheduled appointments that are canceled with less than 24 hours’ notice and same day appointments canceled with less than 2 hours’ notice. We cannot accept cancellations of appointments left online.   

Urgent Care Hours/Holidays

  • Appointments Monday – Friday before 8am and 5pm or later, appointments during our weekend hours, and same day appointments during a holiday are considered to be “urgent care.”
  • There is a fee of up to $45.00 for each urgent care visit and a fee of $45.00 for each urgent care visit on a holiday. This fee will be billed to the insurance we have on file, but if it is denied this fee will become your responsibility.


Village Pediatrics of Chapel Hill does not currently charge for any form completion or for after hour nurse/triage calls.


Important note about Billing

Insurance companies have very specific regulations about billing for health care services.  As your health care providers, we are required to follow those regulations in how we report services provided to you. All physicians/providers must report to the insurance company in a universal code system linked to the service, treatment or procedure provided. It is not uncommon for a patient to receive a regular check-up and an evaluation of an acute or chronic illness (ex: ADD/ADHD, asthma, ear aches, and sore throats). In these cases, your insurance may be billed for a well child exam and an additional office visit. 

Insurance companies handle these reported codes differently. Some insurance companies may require an additional co-pay to cover the charge and/or the charge may go towards your co-insurance or deductible; this is determined entirely by your insurance company. If you have questions, please check with your insurance carrier. 

We appreciate the opportunity to participate in your family’s healthcare. As always, we are dedicated to providing the best possible care for your family. If our billing office can help, please contact them at (919)-969-9611.   

I have read, understand, and agree to the above financial policy. I understand that charges not covered by my insurance company, as well as applicable co-pays and deductibles are my responsibility.

Parent Signature Date
Parent Name (PRINT, please) DOB:
Child’s Name (PRINT): DOB:
Child’s Name (PRINT): DOB:
Child’s Name (PRINT): DOB:
Child’s Name (PRINT): DOB:

You can dowload a pdf copy here.

Office Hours

Avance Care Pediatrics

Monday - Friday
8:00 am - 5:00 pm
8:30 am - 12:00 pm
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