Facesheet

ABC PEDIATRICS, LTD

Patient #1 Information

Patient(s) Address

Authorization for the Treatment of Minors

I authorize the following (someone other than parent or guardian) to bring my child/children listed above to ABC Pediatrics, Ltd. for medical care without my express prior authorization.

Pharmacy Information

Credit Card on File

In an effort to improve patient service and office efficiency, ABC Pediatrics, Ltd. has implemented a credit card on file policy. Much like many other businesses such as a hotel or car rental agency, attorney, etc. we have a similar policy where we ask for a credit card which may be used later to pay any balance that may be due on your bill. Co-pays are due at the time of service.

At check-in, your credit card information will be obtained and kept securely until your insurance has paid its portion and notifies us of the balance due, if any. At that time, you will be sent a statement which you will have 14 days to review and pay your balance. After 14 days, if the bill remains unpaid, we will bill your credit card.

This does not compromise your ability to dispute a charge or question your insurance company’s determination of payment. We recommend you contact your insurance company first for any discrepancies.

Authorization and Acknowledgement

• I understand copies of the Notice of Privacy Practices (HIPAA), Financial Policy, Cancellation/No Show Policy, and Electronic Communication Policy are posted in the office and on the website, www.abcpediatrics.net. I understand that I am bound by the terms of these policies and failure to do so could result in dismissal.
• I authorize you to give my child/children reasonable and proper medical care by today's standards.
• I authorize the physician to release information related to any claim.
• I recognize and accept full responsibility for all professional services rendered and further authorize the insurance company to pay benefits directly to the physician.
• I understand that I must give at least one-hour notice when canceling a sick appointment and at least 24-hour notice when canceling a well visit, otherwise, I will be charged a $50 fee.
• I understand that I am responsible for deductibles or uncovered expenses. This may include charges for screening forms, lab tests, and vision screenings that are required by law or recommended by the American Academy of Pediatrics.
• I understand that an additional charge will be incurred for patients seen in the office during regularly scheduled evening, weekend, or holiday office hours.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.