(Unless you specify otherwise when you call, this is the number we will use if we ever need to call in a prescription. It is your responsibility to update this information with us.)
Please make sure to provide the office staff with a copy of both sides of your health insurance card. It is your responsibility to advise us of any changes in your insurance coverage (including co-pay changes) as soon as they occur, in order for the billing process to go as smoothly as possible.
Primary Health Insurance Coverage
Secondary Health Insurance Coverage
In order to control our billing costs, payment is expected when services are rendered.
I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits to Mt. Airy Pediatrics. I understand that I am financially responsible for any balance not covered by my insurance carrier. A copy of this signature is as valid as the original.
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This form MUST signed and it is your responsibility to update your information with us as soon as it changes.
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