Smita Parikh Mengers, MD FAAP & Wendy R. VanBronkhorst, MD FAAP
certify that there is no other commercial insurance policy or privately held insurance policy that covers the child listed above. I understand that withholding information about any other insurance policies is considered fraud. I understand that, if the insurance company retracts payment because the child listed above does have other insurance, I am responsible for payment. I understand that, if in the future, the insurance carrier retracts payment for services rendered to my child for any reason, or if the insurance carrier does not pay the charges, I am responsible for payment. I also certify that I have chosen Dr. Mengers or Dr. VanBronkhorst as my child's primary care physician and that I have made the Insurance carrier aware of my choice.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
The provider is not required to verify responses by the parent, guardian, or individual of record.
The provider's office must keep this form for each child (birth through 18 years of age) who receives immunizations through the Vaccines for Children (VFC) Program in Maryland in the patient's permanent medical record for six years. The health care provider or the parent, guardian, or individual of record may complete this form, and should complete a new form if the child's status changes. The provider may use this record for all subsequent visits as long as there is no change in the child's eligibility status.
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