WHO TO CONTACT IF WE CAN'T REACH PARENT/GUARDIAN IN AN EMERGENCY?
The guarantor is responsible for all fees. Fees are due at the time of service.
Please read and sign the following Authorization and Assignment.
Insurance Authorization & Assignment
I hereby authorize Ofelia B. Ayuste, M.D.S.C. to furnish information to my insurance company carrier concerning my child or children's illness or treatment. I also hereby assign the Doctor all outstanding payments for medical services rendered to my dependent(s). I UNDERSTAND I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY MY INSURANCE.
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.