New Patient - Existing Patient Form

Please correct the errors described below.

List anyone we can leave appointment information with other patient:

Relationship to patient and phone

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Responsible Party if Other Than Self/Insurance

Insurance Information

    Please upload a file
      Please upload a file

      The above information is true and to the best of my knowledge. I authorize mu insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance due. I understand if my bill is transferred to a professional collection agency I will be charged an additional 33% of my outstanding balance as well as any collecting attorney fees. I also authorize Anniston Pediatrics, Inc. or insurance company to release any information required to process my claims. I understand that a copy of the Practice Information form for Anniston Pediatrics, Inc. is always available.

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