We are pleased to provide a Patient Portal in partnership with our electronic medical records provider, Office Practicum for the exclusive use of established patients. The Patient Portal is designed to enhance patient – physician communication.
Who should receive billing statements?
PLEASE PROVIDE ADDRESS IF DIFFERENT FROM THE PRIMARY OR SECONDARY CONTACT:
If parents are divorced or separated please fill out this section:
I GIVE PERMISSION FOR THE FOLLOWING PERSON(S) TO ACCOMPANY MY CHILD FOR MEDICAL TREATMENT AND TO MAKE MEDICAL DECISIONS IN MY ABSENCE:
I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO PEDIATRIC ASSOCIATES OF LAWRENCEVILLE, LLC AND I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS. I VOLUNTARILY CONSENT TO EXAMINATION AND TREATMENT OF MYSELF/OR MY DEPENDENTS. I WILL BE RESPONSIBLE FOR THE FULL AMOUNT OF THE CHARGES EXCEPT THOSE UNDER THE CONTRACTUAL ARRANGEMENTS WITH CERTAIN INSURERS OF PEDIATRIC ASSOCIATES OF LAWRENCEVILLE, LLC.
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.
Your information will be encrypted.