Authorization Billing ledger 1

Estrella Pediatrics, P.C.

9520 W Palm Ln, Suite 100

Phoenix, AZ 85037

(623) 388-3216 (623)388-4902

AUTHORIZATION TO RELEASE BILLING LEDGER
Patient Name*

First Name Last Name
Date of Birth*

MonthDayYear
Date
Patient Name

First Name Last Name
Date of Birth

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address
Phone Number
Please provide at least one number (in case we need to reach you.)
Work Number
Cellular Number
I hereby authorize Estrella Pediatrics, P.C. to send/release the billing ledger concerning the above named patient(s) to:
Name of person/place receiving information. For example: parent, office, government agency, etc.
Release information via the following method:*

MailFaxEmailIn person
Address to mail document to:
Fill in complete mailing address.
Fax Number
Please enter a valid phone number.
Email
example@example.com
This information is to be disclosed for the purpose of:*
I authorize the release of the billing ledger. I understand that when my child's information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA privacy rule. The Practice, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized here in.
Patient or Personal Representative's Full Name:*

First NameLast Name
By signing this form electronically, I hereby declare that I am the individual identified in this form and have the legal right to request this information. I acknowledge that any false misrepresentation may result in legal consequences.
Patient or Personal Representative's Signature*

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Relationship to Patient*
Date*

MonthDayYear
Date
EPPC 10-24
Should be Empty:

EPPC 10-24