Patient Consent for Treatment & Letter of Guaranty

CONSENT FOR TREATEMENT

I hereby apply for treatment at Pedi Med Center and give permission for any attending physician or non-physician provider (PA, CFNP or CPNP) of the Pedi Med Center staff, and for any consultant or assistant who he or she may call to his or her aide, to administer treatment and/or medication deemed necessary for the care and treatment of my child. I authorize the employees of Pedi Med Center to assist my physician/non-physician provider in any way deemed necessary for such treatment.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

LETTER OF GUARANTY

2. Guarantor is making this guaranty in exchange for one of the Providers from Sari Nabulsi, MD, LTD, LLP providing medical services to Guarantor’s child.

3. Guarantor accepts and understands that all charges incurred in the treatment of the Guarantor’s child shall be the sole responsibility of the Guarantor.

4. Guarantor shall be responsible for all medical services and charges incurred for same if child gets married, is no longer covered by Guarantor’s insurance, reaches the age of majority, no longer resides with Guarantor, or any other situation.

5. Guarantor is guaranteeing that he/she will provide payment for all services rendered and charges incurred in the treatment of the child.

6. Guarantor understands THAT NEITHER ANY OF THE PROVIDERS OF SARI NABULSI MD, LTD, LLP NOR ANY OF ITS AGENTS, EMPLOYEES OR OTHER STAFF WILL AT ANY TIME FILE THE CHARGES INCURRED IN THE TREATMENT OF GUARANTOR’S CHILD WITH MEDICAID.

7. Guarantor understands that he/she is requesting PRIVATE PAY rather than MEDICAID and as such, will be solely and fully responsible for the entirety of any charges incurred by the child for whom the Guarantor is guaranteeing this payment.

8. Payment for all services rendered to Guarantor’s child shall be made at such time as services are rendered.

9. This guarantee may only be amended or modified in writing. This guaranty may not be amended or modified orally.

10. This letter of Guaranty shall be construed under and in accordance with the laws of the State of Texas, and all obligations of the parties created in this agreement are performable in Midland, Midland County, Texas. Payment in full for all services rendered under this agreement is expected at the time such services are rendered.

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.