GP Admin Fee Acknowledgment Form

Annual Administrative Fee Acknowledgement

Glendale Pediatrics has instituted an annual Administrative Fee. The Administrative Fee is intended to cover administrative services not covered by health insurance. I have read and understand the Annual Administrative fee policy. By signing below, I agree to assume financial responsibility for the payment of the Administrative Fee.
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient's Parent Legal Guardian Printed Name First and Last*
Patient's Parent Legal Guardian Signature*

Clear
Relationship to Patient*
Date*

MonthDayYear
Date
Email*
example@example.com
Patient - 18 years or older

If patient is 18 years or older, please print name, DOB and sign.
Printed Name
Date of Birth

MonthDayYear
Date
Patient Email
example@example.com
Signature

Clear
Date

MonthDayYear
Date
Family Size
Family Size: Please check*

$90 (1 child)$150 (2 children)$180 (3 or more children)
Month Paid*
Initials: Initials I authorize Glendale Pediatrics to charge my annual Administration Fee each year on the credit card noted below. The authorization will automatically renew at the credit card's expiration date and remain in force on each of my children's accounts until they are no longer patients of Glendale Pediatrics. Patients will be notified 30 days in advance if the annual administrative form fees are modified in the future.
Print Cardholder's Name*
Cardholder's email*
example@example.com
Card Type*

VISAMCDISAM EX
Last 4 Credit Card Numbers
Exp Date
CVV
Date*

MonthDayYear
Date
Cardholder's Signature*

Clear
Disclosure: The administrative fee is non-refundable.

As HSA and FSA programs vary greatly, please check with your program administrator to determine if this annual administration fee is HSA or FSA-eligible
Should be Empty:

Patient - 18 years or older

Family Size