List Person(s) to contact in case of an emergency and person(s) authorized to bring child to visits and have access to "ALL" patient medical and financial information.
I acknowledge I have read and understand the disclosures, billing policies of Partners in Pediatrics, LLC and I am responsible for payment.
I, as the parent, guardian or legal personal representative, give my permission to Partners in Pediatrics, LLC and their employees to provide medical care to my child. I realize I am responsible for accompanying my child or children while on the premises. According to HIPAA law, I shall update this information at least annually or sooner if any information changes.
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.
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