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UTILITY WAIVERS The Pediatric Department at Starling Physicians recognizes that financial hardships exist which occasionally makes it difficult for patients to meet financial obligations in payment of utility bills. It is this department’s policy not to get involved in fiscal matters of patients, nor to condone poor fiscal management on the part of patients. Payment of utility bills should be foremost, and as important as other non-essential bills often provided for in the family budget. The primary goal of this department is to provide medical care and sound medical advice to patients. Not sign utility waivers. If your utility carrier requires a medical form to be completed, we may do this on an exception basis only. The form may be signed only upon reviewing your child’s medical condition. Please note, that a “life-threatening illness” is a condition that includes, but is not limited to being ventilator dependent, gastrostomy tube dependent or on a cardiopulmonary monitor. If we determine that in the absence of this signed form, your child’s health may be compromised, we will sign the form. However, this will be a one-time exception only that is made, in signing utility forms on behalf of your child.

Utility Waiver Policy...If your utility carrier requires a medical form to be completed, we may do this on an exception basis only. The form may be signed only upon reviewing your

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Page 1: Utility Waiver Policy...If your utility carrier requires a medical form to be completed, we may do this on an exception basis only. The form may be signed only upon reviewing your

UTILITYWAIVERS

ThePediatricDepartmentatStarlingPhysiciansrecognizesthatfinancialhardshipsexistwhichoccasionallymakesitdifficultforpatientstomeetfinancialobligationsinpaymentofutilitybills.Itisthisdepartment’spolicynottogetinvolvedinfiscalmattersofpatients,nortocondonepoorfiscalmanagementonthepartofpatients.Paymentofutilitybillsshouldbeforemost,andasimportantasothernon-essentialbillsoftenprovidedforinthefamilybudget.Theprimarygoalofthisdepartmentistoprovidemedicalcareandsoundmedicaladvicetopatients.Notsignutilitywaivers.Ifyourutilitycarrierrequiresamedicalformtobecompleted,wemaydothisonanexceptionbasisonly.Theformmaybesignedonlyuponreviewingyourchild’smedicalcondition.Pleasenote,thata“life-threateningillness”isaconditionthatincludes,butisnotlimitedtobeingventilatordependent,gastrostomytubedependentoronacardiopulmonarymonitor.Ifwedeterminethatintheabsenceofthissignedform,yourchild’shealthmaybecompromised,wewillsigntheform.However,thiswillbeaone-timeexceptiononlythatismade,insigningutilityformsonbehalfofyourchild.

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