KAP New Born Insurance Waiver Agreement

Please correct the errors described below.

IT IS THE PARENTS’ RESPONSIBILITY TO PROVIDE OUR OFFICE WITH THE INSURANCE INFORMATION IN A TIMELY MANNER AND FOLLOW UP WITH THE INSURANCE COMPANY UNTIL ELIGIBILITY CAN BE VERIFIED.

REASONS FOR THIS WAIVER:

IMPORTANT: We must have your child’s insurance card or written verification from your insurance company that your child is currently eligible for benefits by the 1 month well baby exam. If you do not have this available, the visit will need to be paid in full and any previous/outstanding balances on the account for any other family member/patient. Any applicable credit amounts will be refunded to you once contracted insurance information is received and paid dates of service are with confirmed or paid by the insurance.

IMPORTANT: Policy holder must contact our office within 10 days of new insurance coverage. Suitable payment arrangements must be made up-front for new insurance/policies. Any applicable credit amounts will be refunded once contracted insurance information is received and paid dates of service are confirmed or paid by the insurance.

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.

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