New Patient Registration Form

Pediatric Health Center of Conyers

Please correct the errors described below.

IN CASE OF EMERGENCY PLEASE CONTACT (someone other than parent)

INSURANCE INFORMATION

I HEREBY AUTHORIZE PAYMENT DIRECTLY TO PEDIATRIC HEALTH CENTER OF ALL SURGICAL AND/OR MEDICAL BENEFITS, IF ANY, FOR HIS SERVICES PROVIDED FOR MY CHILD WHICH YOUR OFFICE MAY FILE ON MY BEHALF. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR THE CHARGES NOT COVERED BY THIS AUTHORIZATION. I UNDERSTAND THAT IF A BALANCE ON THIS ACCOUNT IS UNPAID AFTER THIRTY (30) DAYS ON OFFICE VISITS OR SIXTY (60) DAYS ON HOSPITAL CHARGES, I AM RESPONSIBLE FOR ALL COLLECTION FEES INCURRED IN ORDER TO COLLECT THE BALANCE. ALL OFFICE VISITS AND SERVICES ARE DUE AND PAYABLE AT TIME OF SERVICE, UNLESS, OTHER ARRANGEMENTS HAVE BEEN MADE PRIOR TO YOUR VISIT. I UNDERSTAND THAT ALL CONTRACTED INSURANCE CLAIMS WILL BE FILED, BUT THE GUARANTOR IS ULTIMATELY RESPONSIBLE FOR ALL FEES INCURRED. I HEREBY AUTHORIZE RELEASE OF ANY RECORDS/ INFO FROM PREVIOUS AND REF HOSPITALS/PROVIDERS TO PHC NECESSARY FOR MEDICAL TREATMENT OR TO PROCESS ANY CLAIMS FILED ON MY CHILD’S BEHALF. 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.

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