PEDI MED CENTER
Your receipt for each visit will contain all the information needed to process an insurance claim. Please remember that insurance is a method of reimbursing you for fees paid to the doctor and is not a substitute for payment.
I hereby assign to Sari Nabulsi, MD, LTD, LLP all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. The above registration information is correct to the best of my knowledge and I understand and accept the above payment policy.
I hereby authorize Sari Nabulsi, MD, LTD, LLP to release any pertinent medical information to my insurance carriers for myself or dependents.
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.
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