Child Intake Form

Please correct the errors described below.
Please indicate the name of the clinician you have an appointment with.

Medical Information

Your insurance is a method for you to receive reimbursement for fees you have paid to the physician for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based upon your contract with them, not with our office. It is your responsibility to pay the deductible, coinsurance, and any other balances not paid for by your insurance. We will do all that we can to assist you in receiving reimbursement, but you are responsible for your bill.

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES. I HAVE READ THIS INFORMATION AND UNDERSTAND IT.

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