Patient Information Form (Page 7 of 7) in pdf

Patient Information Form Page 7

IMPORTANT NOTICE

We attempt to refer you to providers, labs, and x-ray facilities that are contracted with most

health plans.

PLEASE BE AWARE THAT IT IS YOUR

RESPONSIBILITY TO KNOW THE DETAILS

OF YOUR HEALTH PLAN

If you are in doubt as to whether a procedure, lab test, or x-ray is covered or if you are unsure as

to where it must be performed, please call your insurance carrier for assistance.

Effective August 1, 2012 there will be a $25.00 reprocessing fee for rebilling your

insurance, if you have not provided us with the correct insurance or your insurance

premium is received late by your insurance company.

Effective August 1, 2012 there will be a $15.00 charge for any patient forms

needed to be completed.

Effective August 1, 2012 there will be $35.00 charge for copying any patient(s)

records.

This office will not be responsible for your out-of-pocket expenses from utilizing the wrong

provider or undergoing non-covered vaccines or procedures.

Only cash or check payment is acceptable for all the above charges.

Print Parent Name:_____________________________________________________________

Parent Signature:______________________________________________________________

Print Patient Name:____________________________________________________________

Witness:____________________________________

Date:_______________________

Patient Information Form Page 7