I certify that my child(ren) has/have the commercial insurance coverage(s) referenced above. I understand that my child(ren) is/are being accepted as
new patients with ESD Pediatric Group contingent upon maintaining primary and secondary (if applicable) commercial health insurance which is
currently accepted by the practice for a minimum of twelve (12) months. Should commercial insurance lapse or the child(ren) become(s) ineligible for
coverage during the twelve (12) month period, the patient(s) will receive a written notification of dismissal.
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