PATIENT DISCLOSURES AND FINANCIAL RESPONSIBILITY:

· I authorize direct payment of insurance benefits to Pediatric & Adolescent care for services rendered to my dependents.

· I agree to pay any copayments, deductibles, or remaining balances that my insurance company does not reimburse. I understand that I am financially responsible for any services that I request and receive even if they are not deemed medically necessary by the physician or my insurance company.

· I agree to the No Show Policy which states:

· For Commercial Insurances, a $25 fee will be charged for appointments that are not canceled or rescheduled at least 24 hours before the scheduled time.

· For patients with Medicaid or who are Self-pay, if your child misses three appointments without providing at least 24 hours’ notice, your child may be dismissed from our practice.

PROTECTED HEALTH INFORMATION:

· I certify that I have acknowledged and read a copy of the Pediatric and Adolescent Care M.D. “Notice of privacy practices.”

This notice describes how the clinic may use and disclose my protected health information, certain restriction on the use and disclosure of my health care information and my rights regarding such information.

· I authorize the clinic to release and receive any of my dependents medical or incidental non-public personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits.

· I understand the privacy risk of the mail, phone calls, and email.

· I authorize the staff of Pediatrics and Adolescent Care M.D., P.A. to mail, call, SMS text or email me with communication regarding medical care, including but not limited to appointment reminders, medical and insurance information.

· I understand that I have the right to revoke this authorization at any time by notifying the clinic in writing.

*Initials: _____

Name of Parent/Guardian: _____________________________________

Signature of parent/guardian ________________________________________

Date _________________________________

PATIENT DISCLOSURES AND FINANCIAL RESPONSIBILITY:

Pediatrics & Adolescent Care