Additional Parents/Guardians
Primary Insurance
Secondary Insurance
PLEASE READ AND SIGN BELOW
MEDICAL CONSENT/ASSIGNMENT/RELEASE: I hereby agree to medical treatment rendered under control of West Valley Pediatrics, PC. I hereby assign my insurance benefits to be paid directly to West Valley Pediatrics, PC and I am financially responsible for any non-covered services. I also authorize West Valley Pediatrics, PC to release information as necessary to process all claims for services rendered. Rev 6/20
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.
The following individuals have my permission to bring my child to West Valley Pediatrics for medical care and treatment. I also authorize the same individuals to receive medical advice and information concerning my child, whether in office or over the phone. These individuals will also serve as emergency contacts for my child.
Additional Name
Thank you for choosing West Valley Pediatrics (WVP) as your primary care physicians. This policy has been put in place to ensure that financial payments due are recovered to allow us to continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager and billing department will be glad to discuss these policies with you.
Please carefully read and initial by each statement and sign below
I have read and I understand the above policies of West Valley Pediatrics
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Upon request, a physical copy of our HIPAA policies is available for you to read while in the office
Signature below is only acknowledgement that you have received this Notice of our Privacy Practices
The providers and staff of West Valley Pediatrics are here to take care of children. Our focus is on the medical, psychological and emotional health of your child(ren)- NOT legal issues involving divorce, separation, or custody agreements. That is why we ask that you read and agree to the following
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