Responsible Party Information (Person responsible for paying bills/guarantor)
Patient's Insurance Information
Assignment of benefits - Financial agreement
I hereby give authorization, unless revoked by me in writing, for payment of insurance benefits to be made directly to Pediatrics for You, PLLC/Shakti K. Matta, MD, and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not covered by insurance. In the event of default, I agree to pay all costs of collection and reasonable attorney fees. I hereby authorize Shakti K. Matta, MD, and his staff to release all information necessary to secure payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original. I acknowledge receipt of notice of privacy practices.