Secure Forms

Release of Information for Insurance



Today
 
 
 
 
 
 
 
 

I authorize the physicians and staff of Pediatric Professional Association to provide necessary and appropriate treatment for my child

I fully understand that I am responsible for charges incurred. I authorize the release of information required to process insurance claims benefits. A photocopy of this form is as valid as the original. If your insurance company has not paid, or this is not timely filed, you will be responsible for payment and any further filing. If your insurance changes and you do not notify us within 30 days, you will be responsible for payment.

 

Cancellation Fee Acknowledgment Notice: A $25 fee will be charged to your account if you cancel without 24-hour advance notice for well checks; unless we agree that you were unable to attend due to circumstances beyond your control. Note: Insurance companies do not reimburse for cancelled appointments.

IMPORTANT

Release of information for other entities

If you desire Pediatric Professional Association to disclose your child’s medical information to a third party, including but not limited to, your child’s school or daycare, you must complete an authorization form. This authorization is located on the other side of this paper. Pediatric Professional Association cannot disclose your child’s medical information to a third party unless you complete and sign an authorization.