Acknowledgement and Authorization

Please check the boxes below:

I have carefully read the office and financial policies of Clinical Pediatric Associates of North Texas (CPANT), understand and agree to the terms and conditions as stated.If CPANT files insurance on my dependent(s) behalf, I understand I am financially responsible and agree to pay for non-covered services, co-insurance, co-pays and deductibles.I accept legal responsibility for all expenses in treating the patient(s) named below and understand that payment for services is due at the time they are rendered.I understand that CPANT reserves the right to modify the privacy practices outlined in the notice.I understand that I can request a copy of the updated Notice of Privacy Practices by calling my physician's office or requesting a copy in person at my appointment.I have received a copy of the office and financial policies of CPANT.I have received a copy of the Privacy Practices.

Patient Name: Responsible Party Full Name
Signature: Signature Date: Date

I authorize CPANT to release any of my medical information to:
Insurance company(s) as needed to process any claims, to pay CPANT directly for covered medical and/or surgical services. The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for CPANT to share my protected health information with:

Name: Full Name Relationship: Relationship to Patient

Patient Name: Responsible Party Full Name
Signature: Signature Date: Date

Acknowledgement & Authorization 01.2022

Acknowledgement and Authorization

AUTHORIZATION TO RELEASE INFORMATION