I affirm that the information given today is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical information.
I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.