The Professional Association for Pediatrics

GENERAL INFORMATION






PARENT/GUARDIAN INFORMATION

Please fill out the section pertaining to you.



Employer Information:


PRIMARY INSURANCE INFORMATION

We must have a copy of your current insurance card at each visit.




Subscriber's Information:



EMERGENCY CONTACT

Nearest Relative NOT living with you


HISTORY

Medication Allergies


OTHER INSURANCE


RECEIPTS FOR SERVICES RENDERED

Upon the completion of each visit, you are requested to stop at the Bookkeeping Desk for an itemized statement of services rendered. This is the times to be certain that all charges are clearly explained and that they are fully understood. You are given a time of service receipt or insurance receipt upon request. Payment is due at the time of your visit unless previous arrangements have been made.

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

I authorize below the following:
1. Release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in the place of the original.
2. I hereby authorize The Professional Association of Pediatrics to apply for benefits on my behalf for covered services rendered by the association, or by their order. I request that payment from my insurance company be made directly to The Professional Association for Pediatrics.
3. I have been given this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of the document.
4. I certify that my insurance and address listed or corrected above is correct.
5. AUTHORIZATION FOR CARE: I hereby consent to and authorize The Professional Association for Pediatrics and its affiliates, its employees and contractors, to provide services and administer physician orders. This may include: routine care, immunizations and emergency care as deemed necessary by the physician.
6. PORTAL and ONLINE SUBMISSION: I acknowledge that I have read and fully understand this consent form. I have been given risks and benefits of patient portal and submitting personal information online. I agree that I understand the risks associated with online communications between my physician and patient, and consent to the conditions outlined herein. I agree not to hold The Professional Association for Pediatrics or any of its staff or physicians liable for network or security infractions beyond their control. Portal and online form submission is entirely voluntary and will not impact the quality of care I receive from The Professional Association for Pediatrics should I decide against using these services. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that my physician may impose for online communications. I have been proactive about asking questions related to this consent agreement. All of my questions have been answered with clarity. I understand that this agreement is good for life unless I submit written request to be removed.
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