GUARANTOR INFORMATION (PERSON RESPONSIBLE FOR THE BILL)
PRIMARY SUBSCRIBER INFORMATION (PERSON WHO HOLDS THE INSURANCE POLICY)
SECONDARY SUBSCRIBER INFORMATION (IF APPLICABLE. DETERMINED BY ORDER OF BIRTH MONTH)
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Child and Adolescent Health Associates or insurance company to release any information required to process my claims.
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