I authorize Peerless Pediatrics to release to my insurance company, managed care organization, state agency(ies), federal agency(ies), Health Care Financing Administration or Third Party Administrators, any information needed to process my claim and/or determine benefits payable for related services. I further authorize payment directly to Peerless Pediatrics of the insurance benefits received for any claim filed on my behalf.
I grant permission to Peerless Pediatrics to release all or part of my medical record to any consulting entity that may be involved in my medical care. This includes but is not limited to, testing facilities, consulting physicians, and outpatient facilities.
I also authorize Peerless Pediatrics to utilize a fax machine to transmit any or all of the above medical records pertaining to my medical care or Insurance reimbursement. I acknowledge that faxing my medical records may increase the risk of accidental disclosure of my medical records.
I acknowledge that I have read and understand the Financial Policy of Peerless Pediatrics.
I understand that this authorization will be used for one year. If any part of this information changes at any time, I understand it is my responsibility to notify Peerless Pediatrics in writing of any and all changes, realizing that failure to do so may result in additional financial responsibility to me.