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The world of pediatrics is experiencing a high number of “no show” patients
THE WORLD OF PEDIATRICS
3005 Royal Blvd S., STE 100 Alpharetta, GA 30022
Procedures and Services Agreement
We would like to inform you that the following procedures or services will be filed with your insurance company as a courtesy to
you. Your insurance plan may or may not reimburse us for these services if they are performed in our office. Further, these
services may not be covered by your insurance plan, regardless of where they are performed. Please, note that if these services
are not covered or applied to your deductible, you will be financially responsible for the charges.
All patients have the right to elect for us not to perform these services in our office. We can present you with
alternatives to have these services provided at another location (labs) or direct you to a specialist for screenings.
Services & Procedures Insurances May or May Not Fully Reimburse For
Labs, Screenings, Diagnostic Procedures
Insurance policies may or may not cover labs and screenings drawn or performed in the office. Insurance may
or may not cover particular labs, screenings, or diagnostic procedures ordered by Dr. Vayman regardless of
where they are performed. Fees not covered for these services will be the patient’s sole responsibility. The
most common of these are listed below, although this policy applies to all Labs, Screenings, or Diagnostic
Procedures performed, regardless of whether or not they are listed.
Vision and Hearing Screening when done as part of a physical
Urinalysis when done as part of a physical
Hemoglobin when done as part of a physical
Blood Stick Glucose Injections, Vaccines, and Fees for Administering Vaccines
Insurance policies may or may not cover some vaccines or injections that are administered to our patients.
Insurance policies, also, vary in whether or not they cover the administration costs for all vaccines or injections
that are given. Each injection will be charged an administration fee. Charges not covered for these services
and the vaccines or injections themselves will be the patient’s sole responsibility. Several of these are listed
below, although this policy applies to all Injections, Vaccines, or Administration Fees regardless of whether or
not they are listed.
Vaccines or Immunizations
Influenza Shot or Intranasal Influenza Vaccine
Administration Fee for EACH Injection Telephone Consultations
– Insurance policies typically do not cover telephone conferences with
physicians to discuss problems or medical issues. Fees not covered for these services will be the patient’s sole
I have elected to have all procedures listed above performed in the office by Dr. Lyudmila Vayman’s office,
regardless of whether reimbursement will be rendered by my insurance or not. I agree to be solely responsible
for the full cost of these services or the difference not covered by my insurance company.
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