Insurance Coverage is a contract between you and your insurance company. It is your responsibility to know what your plan does and does not cover.
We will file insurance claims for you, but you are responsible for amounts not paid by insurance within 90 days.
I understand that I am responsible for any balance not covered by insurance. I also understand that all co-payments, deductibles and co-insurances are due at the time of service.
As parent or legal guardian, I authorize payment of medical benefits to be made directly to Pediatric & Adolescent Associates, PSC for services performed. I further agree to be fully responsible for all lawful debts incurred for services provided.
I consent to be contacted by regular mail, by email or by telephone (including a cell phone number) regarding any matter related to our account with Pediatric & Adolescent Associates, PSC.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.