Emergency Contact Information (A local person other than Parents or Guarantor)
HIPAA Disclosure (People other than parents/guardians)
(Please provide all the insurances for the child. Not providing all the insurance information will result in the patient being discharged from the practice)
Who is authorized to bring the child(ren) for a visit and make medical decisions on their behalf?
CONSENT FOR EXAMINATION, MEDICAL TREATMENT AND CONDITIONS OF EXAMINATION
INFORMATION CONCERNING FILING A CLAIM WITH YOUR INSURANCE COMPANY
AUTHORIZATION TO FILE INSURANCE CLAIMS, TO RELEASE MEDICAL INFORMATION AND ASSIGNMENT OF BENEFITS
AGREEMENT AS TO CO-PAYMENTS, NON-COVERED OR NON-PAID SERVICES AND GUARANTEE OF PAYMENT
This field is for validation purposes and should be left unchanged.