Patient Information

Please correct the errors described below.

PATIENT INFORMATION: THIS SECTION REFERS TO THE PATIENT ONLY

PARENT AND GUARDIAN INFORMATION

This section refers to the PERSON WHOSE NAME IS LISTED ON THE INSURANCE CARD: SUBSCRIBER INFORMATION

AUTHORIZATION TO PAY BENEFITS TO THE PHYSICIAN

I hereby authorize the office of NAVARRE PEDIATRICS PL to release any medical information required during the course of examination and treatment and permit payment directly to them any benefits due for their services rendered. I recognize and accept responsibility for services rendered regardless of insurance coverage. This include, but is not limited to, coinsurance, co-payment, deductible and non-covered services.

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