IF YOU ARE NOT THE PARENT OF THIS CHILD AND / OR HAVE LEGAL SOLE CUSTODY / PLACEMENT, PLEASE PROVIDE OUR RECEPTIONIST WITH THE LEGAL DOCUMENTATION IN CORESPONDENCE TO THESE CHANGES.
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I the undersigned hereby agree to be responsible for all charges and I understand that payment is to be made at the time service is rendered unless other arrangements are made. If insurance billed, I agree to all payments being made directly to the provider, Samir Mullick M.D., S.C.
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.
PLEASE OFFER INSURANCE CARD TO OUR RECEPTIONIST. IT IS THE RESPONSIBILITY OF THE PARENT /GUARDIAN TO INFORM THIS OFFICE OF ANY CHANGES IN THE ABOVE INFORMATION.
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understand and agree That the services have been rendered for which I am fully responsible, whether or not medical or other Insurance should cover the cost of at least a portion of the services rendered.
I further understand and agree that In the event that I default on any payments due and owing this practice for such service, I will pay any and all costs of collection of such payments due and owing, including, without limitation, reasonable attorney's fees, 3rd party collection agency fees, court cost, and other such costs.
The signature below acknowledges a copy of this Notice was RECEIVED (not necessarily read).
FOR INTERNAL USE ONLY
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Below is a list of persons that you give permission for our clinic to discuss and use the patient's protected health information, including condition and treatment plan, test results, prescriptions, X-rays:
Below is a list of persons that you give permission for our clinic to treat your child when they are brought in by someone other than a parent or a guardian.
I understand that it is my responsibility to update this list in order to keep accurate those authorized persons to receive or use this patient's healthcare information.
I understand and agree that:
Note: A signed parent consent form lasts until the child turns 18 unless withdrawn, If the consent form is not returned, anyone under 18 will not be able to receive general medical services, however confidential reproductive health services are available by state law.
Adolescents under age 18 must have a signed parent/guardian consent form on file to receive some general medical services (including vaccines unless otherwise stated), *According to state law, parental consent is NOT required for pregnancy and contraceptive services, chemical abuse assessment and counseling, or diagnosis/testing and treatment of sexually transmitted infections. If you have any concerns regarding this consent please contact the office.
My teen has permission to receive medical service at Pediatric Associates.
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