It is important to us that you understand our financial policy, and know that we are always willing to answer any questions you might have.
Personal Care Pediatrics is authorized to disclose all or part of the medical record on the above named patient to insurance companies, organizations or agencies responsible for payment of services performed by Personal Care Pediatrics. Also, your insurance company (s), organizations or agencies responsible for payment are authorized to give all medical records to this office. This includes treatment for drug/alcohol abuse, mental health, HIV virus and sexual assault. Although the confidential nature of the information may result in a denial of payment by insurance coverage for services performed in this office.
We may use or disclose your information to family members that are directly involved in your receipt of services with your verbal permission.
Any personal information you provide us with via our website, including your e-mail address, will never be sold or rented to any third party without your express permission. If you provide us with any personal or contact information in order to receive anything from us, we may collect and store that personal data. We do not automatically collect your personal e-mail address simply because you visit our site. In some instances, we may partner with a third party to provide services such as newsletters, surveys to improve our services, health or company updates, and in such case, we may need to provide your contact information to said third parties. This information, however, will only be provided to these third-party partners specifically for these communications, and the third party will not use your information for any other reason. While we may track the volume of visitors on specific pages of our website and download information from specific pages, these numbers are only used in aggregate and without any personal information. This demographic information may be shared with our partners, but it is not linked to any personal information that can identify you or any visitor to our site.
You will be notified immediately if we receive information that there has been a breach involving your PHI.
I, as a patient or guardian of a patient of Personal Care Pediatrics am agreeing to pay Personal Care Pediatrics for services rendered. I authorize payment directly to Personal Care Pediatrics for benefits that may be due and payable under the insurance coverage for the named patient. If I have Medicare or Medicaid I certify that the information given by me in applying for payment under Title XVIII or XIX of the Social Security Act is correct, and request payment of authorized benefits be made payable on my behalf to Personal Care Pediatrics. I authorize copying or using this application for purposes of processing claims and gaining payment.
I have read and am now aware of the above financial statement and authorization of medical release. I have also been provided with Personal Care Pediatrics’ HIPAA Statement of Privacy
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.
I am the patient, parent, or guardian of the following patients:
Your information will be encrypted.