Payment Disclaimer (Credit & Debit Cards)

Payment Authorization & Financial Responsibility Disclaimer

By entering your payment information and submitting a request for services, you authorize My Pediatric Doctor to charge the credit card or debit card provided for all applicable fees associated with your telehealth visit.

You acknowledge and agree that:

  • Payment is required prior to or at the time of service, unless otherwise stated in writing.
  • All telehealth services provided by My Pediatric Doctor are self-pay, unless explicitly indicated.

Charges may include, but are not limited to:

  • Telehealth consultation fees
  • After-hours or urgent care visit fees
  • Additional services provided during the visit

Your card may be charged immediately upon confirmation of your visit or upon completion of services.

You are financially responsible for all charges incurred, including those for services rendered to a minor for whom you are the parent or legal guardian.

All sales are final once services are rendered. Refunds, if any, are issued at the sole discretion of My Pediatric Doctor, except where required by law.

If your payment method is declined, My Pediatric Doctor reserves the right to cancel or suspend services until payment is successfully processed.

Pediatric-Specific Financial Responsibility

Minor Patient Responsibility Statement

By requesting telehealth services for a minor, you represent and warrant that you are the parent or legal guardian of the child and that you accept full financial responsibility for all services provided.

HIPAA Privacy & Security Disclaimer

My Pediatric Doctor is committed to protecting the privacy and security of your health information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable state laws.

Telehealth services provided through My Pediatric Doctor use secure, encrypted technologies designed to protect the confidentiality of Protected Health Information (PHI).

However, you acknowledge that:

  • No electronic communication system can be guaranteed to be 100% secure.
  • There are inherent risks associated with transmitting health information via the internet or mobile devices.

By using our telehealth platform, you consent to:

  • The electronic collection, storage, and transmission of your health information for the purposes of treatment, payment, and healthcare operations.
  • The sharing of PHI with licensed healthcare providers and authorized third-party service providers who are contractually obligated to safeguard your information.

My Pediatric Doctor will not disclose your PHI without authorization, except as permitted or required by law.

For pediatric patients, parents or legal guardians may have access to a minor’s health information as permitted by federal and state law. Certain services may be subject to additional privacy protections depending on the patient’s age and jurisdiction.

Telehealth Limitation & Emergency Clarifier

Not a Substitute for Emergency Care

Telehealth services provided by My Pediatric Doctor are not intended to replace in-person emergency medical care.

If your child is experiencing a medical emergency, including but not limited to difficulty breathing, loss of consciousness, uncontrolled bleeding, or severe trauma, call 911 or go to the nearest emergency department immediately.

HIPAA Notice

This platform complies with HIPAA privacy and security standards. Information shared during your visit is protected and used only for treatment, payment, and healthcare operations as permitted by law.