Patient Enrollment Form

Please correct the errors described below.

Add Parent/Guardian

Add Insurance

Authorization to Pay Benefits to physician:

I hereby authorize direct payments to the above-named corporation. I Understand that Canyon Pediatrics, INC will file an insurance claim on my behalf as a courtesy but I am financially responsible for any and all charges not covered by my insurance company. I also understand that if my account is not paid by myself or the insurance company after ninety (90) days from the date of service it will be turned over to an independent collection agency and a fee of $25 dollars will be added to the account. I certify that I do not have any other insurance carrier at this time.

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

Your information will be encrypted.