*Please only add your children who share the same legal guardians, insurance, and contact information. Otherwise, please fill out a separate form for each child.
Legal Guardian 1
Legal Guardian 2
If you are not the above responsible party the office will need authorization from that party. Please have them fill out this form and return to the office.
If yes, please provide legal documents stating restrictions
Legal documents: Please bring to your visit or email them to email@example.com
Emergency Contact (different than legal guardians)
Insurance Primary Carrier
Insurance Secondary Carrier
I request that payment of authorized commercial insurance benefits be made to [Provide doctor name below] for any service furnished to me or my dependent by Balboa Pediatrics’ providers. I authorize [ Provide doctor name below ] to release medical information which may be required by my insurance carrier to determine payment for services rendered. I further understand that I am responsible to pay certain amounts due the physician at the time of service. These amounts could include annual administrative fees, annual deductibles, copayments, charges denied as not covered by my commercial insurance carrier, and charges denied for services determined as not medically necessary. I further understand any fees associated with collecting reimbursement on my account, I will be responsible for paying all of those fees.
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