20925 Professional Plaza,Suite # 100

Ashburn, VA 20147

Phone: (703) 723-8900 | Fax: (703) 723-8400

Financial Policy


Whole Child is committed to quality and affordable medical care. We are your child’s medical home and we strongly believe that every child is entitled to the highest level of pediatric care regardless of family circumstance. As part of our commitment, we provide a wide range of options to cover the cost of providing care to your children and we are always willing to work with families to solve problems as they come up. We also provide many services that other practices charge for free of charge. That is part of the Whole Child Difference!
In order to make sure that we can continue to provide services for all of our Whole Child patients, we do ask that our families respect certain financial responsibilities. These responsibilities are discussed below. The parent/guardian who brings the patient to our office is the one responsible for all charges and payments.
You are responsible for providing us with your current insurance information and if your insurance changes please notify our front desk as soon as possible. We do participate in most insurance plans.
Your insurance plan contracts with us and requires us to abide by its rules for payment and coverage. These may not always be the services or medications that a child needs. We will try to provide coverage within the limits set by your insurance company, but we will never compromise your child’s health. You are responsible for knowing what your plan covers and does not cover. We also will check your coverage and if we find out that a service might not be covered by your insurance, we will make every effort to let you know that before the service is provided.
Insurance companies set a co-pay as part of your coverage and they require that we collect this fee at the time of your visit. Please have your co-pay ready at check-in. As part of the Affordable Care Act, most preventive care, including Well Visits for children, are covered with no co-pay. However, if an additional diagnosis is made during your Well visit (for example, if your child is sick and we provide a service for that), your insurance company will require a copay, which we collect at the time of your visit.
Each insurance plan has different benefits and most have deductibles that must be paid first by the patient before coverage kicks in. If at your visit, we cannot establish exactly what your obligation is, we may either collect full payment during your visit or submit the bill to your carrier and bill you later. In all cases, you are responsible for paying any amount not covered by insurance.
Many billing questions can be answered by our front desk. In addition, Whole Child is proud to partner with ESM Billing, a local Loudoun County company with many years of experience in medical billing, to handle all your billing needs. This allows Whole Child to focus on what is most important to us, which is providing quality care to your child. If you have any questions about your bill, please contact Veronica at 703-723-4484 or 
You will be sent a bill each month summarizing all charges to your account and all payments received from you or your insurance company. All balances are due in 30 days. Any overdue balance (more than 40 days) may be subject to a late fee. We are committed to providing excellent medical care to your child. We understand that medical care can often be unexpected and expensive, and that personal financial circumstances can change. We do not wish that to affect your child’s health and care and we therefore are willing to work with our families to make payment arrangements that meet your needs. If you are having difficulty paying your balance, please speak to our Office Manager and will be happy to assist you by setting up a payment plan without accruing additional late fees. As with many issues in life, good communication is the key. If you have a long overdue balance and we do not hear, we may have to suspend non-urgent care. So please contact us first so that we can continue to provide the care that your child needs and deserves.
We know circumstance can occur before your appointment and that life and traffic happens, so we understand that sometimes you cannot make your appointment. At the same time, we are a busy practice and if we hold an appointment for you, it means that another patient
cannot be scheduled for that time slot. Therefore, please call our office in advance and as soon as possible if you cannot make your appointment!
• Cancellation - Please call us to cancel 24 hours in advance or to change an appointment. If you do not call to cancel in advance, we may charge you a No-Show Fee of $30 in the case of a missed physical/well child/sick visits. Missed Consultation appointments will be charged $50 because it is a longer appointment.
• Repeated missed appointments or no show - If you miss 3 appointments in a 12-month period without notifying us, we may have to ask you to transfer to another practice so that we can ensure we have enough appointment slots for our other patients.
• Late to an appointment - If you are more than 10 minutes late for an appointment, we will still try to fit you in to our schedule but we cannot promise that will be possible. If we are unable to adjust your appointment time, you will need to reschedule that appointment and a late cancellation fee will apply to your account. So, please arrive at your appointment on time or call our office at least 24 hours in advance if you need to reschedule or cancel.
If you pay by check and your check is returned for insufficient funds, you will be responsible for the amount of the check, and a returned check fee $25. If this occurs multiple times, we may require all future payment in cash or by credit card.
Health insurance plans do not cover the cost of researching, filling out and signing forms. We provide many forms to you free of charge. For other forms, we charge a small fee to cover the costs of completing them. The fee will be charged at the time of check-in or when we receive your forms via email or mail. Please allow three business days for completion of the form. If you prefer to receive these forms via email, please make your request via email and authorize us to send this information back to you via email as well.
Sport Physical Form..........................................$10 (add $10 if want rushed w/in 24 hours)
Virginia School Form ........................................$15 (add $10 if want rushed w/in 48 hours)
Camp Form .......................................................$10
Letters with our Practice’ Letterhead
signed by medical staff........................................NO FEE, depending on the level of detail
Asthma Medication ….........................................NO FEE
Home Health/Therapy………………....................NO FEE
Pre-authorization/medication forms….................NO FEE
School Excuses ..................................................NO FEE
Immunization record ...........................................NO FEE
Physical Exam Copy............................................NO FEE
Medication Refill..................................................NO FEE
We are happy to assist our patients in obtaining prescription refills. In some situations, we can have a prescription prepared for you to pick up or called in to your pharmacy, but we do ask that you give us 2-3 business days, because our doctors are busy all day seeing patients and will need time to review your chart. This service is provided to you free of charge. In some cases, however, certain medications cannot safely be refilled without a patient visit and reevaluation. In that case, we will ask you to schedule an appointment and there will be a charge for that appointment.
The Virginia Department of Education requires that this physical assessment occur on or after May 1 of current school year for the following sports season. We recommend yearly physicals for all children and teens. For Athletes, please schedule this health assessment after May 1 for the following school year. Insurance may not cover a sports physical, if it is done in addition to an annual well visit, but we are happy to do them with your annual visit if it satisfies state, school and insurance requirements. We charge a fee of $10 to fill out a sports physical form. If a separate sports physical is not covered, we can provide the physical and the form for a fee of $60.
These appointments are to help prevent a visit to the emergency room and urgent care. We allocate many slots throughout the day for Same Day Sick appointments and we make every effort to see all patients who need to be seen on the same day. Occasionally, we may have more sick patients than allocated slots and we may be required to triage and give priority to the children who need to be seen the most. If your child is sick, we ask that you call us as soon as possible so that we can give you a same day appointment. As a further service to our patients, we provide evening care until 8 p.m. on some days, as well as Saturday morning hours. We also have walk-in hours with no appointment necessary 7:30 A.M.-8:30 A.M. Monday-Friday.
If you have a medical emergency at any time, please call 911. If you need to speak to a doctor after hours, we provide afterhours telephone service. We are devoted to our patients and we understand that your child's health is a 24/7 concern, so we have providers on call after hours to answer your serious concerns about your child’s health that cannot wait until the next business day. Unlike many practices, we are happy to provide this service free of charge to you. We never want ability to pay to interfere with the care of your child. However, in order for us to continue to provide this courtesy to our patients, please reserve your after hours and overnight calls to urgent situations that cannot wait until the next business day. Non-urgent, routine questions, lab results, appointments and prescription refills can be managed during regular office hours or you can leave us a message, which we will return the next business day.
If you do need to speak to us after hours, please call our office at 703-723-8900 and wait until the announcement is done. Our answering service will pick up and take down information from you and then text the doctor on call. A physician should return your call within approximately 30 minutes. If you have not received a call back, please call the answering service again at the above number.
These are covered by most health insurance plans. If you do not have any coverage or your insurance does not cover vaccines, we will provide them to your child free of charge through the Virginia Vaccine for Children (VVFC) program. We may charge an administration fee of $25 for each vaccine not covered by insurance.
I hereby acknowledge that I have read and understand Whole Child Pediatrics’ Financial Policy.

Parent/Legal Guardian Signature : ______________________________ Date             : ________________________
Patients Name                              : ______________________________ Date of Birth :________________________