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  • Saugatuck Pediatrics LLC

    191 Post Road West, Suite 201

    Westport, CT 06880

    Phone (203) 793-4747

    Fax (877) 809-0848

    www.saugatuckpeds.com

  • I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain privacy rights regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of Saugatuck Pediatrics’ Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.  
     
    I understand that federal law permits Saugatuck Pediatrics to use my protected health information (“PHI”) for a variety of purposes including, but not limited to, treatment, to obtain payment, for healthcare operations, and when required by law for public health purposes. I understand that Saugatuck Pediatrics may need to contact my guarantor (person responsible for payment of medical bills) and/or the policy holder for my insurance to exchange information, when necessary for the purpose of obtaining payment. By signing this form, I acknowledge and consent to these practices.  
     
    I understand that I am ultimately responsible for payment of my medical bills. I agree to pay all copays and charges not covered by my insurance. In addition, the following person is delegated responsibility for my medical bills (guarantor; usually a parent whose insurance policy covers me) and may communicate with Saugatuck Pediatrics LLC about bills:  

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  • I give Saugatuck Pediatrics LLC permission to speak to:

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