I/we agree to:
- Give the doctors and staff permission to examine and treat my child.
- Authorize release of information to my insurance carrier for the purpose of processing claims. I hereby assign medical insurance benefits, to include major medical, to the doctors at ABC Pediatrics.
- Pay for services when rendered unless other arrangements are made prior to the visit.
- Should my account become delinquent, I agree to pay the necessary collection and/or attorney’s fees.
- Use of the after-hours triage service will be assessed a $20 fee if my insurance company does not pay in full.
- Be financially responsible for all charges deemed to be “non-covered benefits” by my insurance company even if the insurance’s Explanation of Benefits state the procedure is a “non-covered benefit” and “patient is not responsible.”
- Keep appointments in a timely manner. If not, I realize if I am 15 or more minutes late, my appointment may need to be rescheduled.
This assignment will remain in effect until revoked by me in writing.