New Patient Sign Up for PEDIATRIC CLINIC LLC

PLEASE FILL OUT ALL LINES COMPLETELY

I acknowledge that I am financially responsible for all services rendered for my minor child. I also acknowledge that in the State of Alabama, both parents are both, separately, 100% financially responsible for the healthcare expenses of their minor children regardless of any divorce decree or any other agreements unless parental rights have been terminated.

First & Last Name of Parent / Guardian on Account

Social Security Number of Parent / Guardian

Parent / Guardian Date of Birth

Relationship to Patient (e.g. mother, father, guardian, etc.)

Cell Phone

Home Phone

Work Phone

Email address

Full Street Address

City, State, Zip

INFORMATION FOR OTHER PARENT / GUARDIAN TO BE LISTED ON ACCOUNT

First & Last Name of the Other Parent / Guardian

Relationship to Patient

Social Security Number of other Parent / Guardian

Date of Birth of Other Parent / Guardian

Full Street Address (if different from above)

City, State, Zip

Cell Phone

Work Phone

Email Address

Child / Patient - First Name

Middle Name

Last Name

Child / Patient Sex (Male or Female)

Child / Patient Date of Birth

Emergency Contact, Phone Number, Relationship to Patient

Emergency Contact (2), Phone Number, Relationship to Patient

Pediatric Clinic Terms of Service:
Non-Covered Service, No-Show Policy, Billing Fee, Collection Fees, Etc: I am aware of the services and procedures (to be) performed today for my child's continued health care. I have been made aware that my insurance may not pay for well visits, blood drawing fees, immunizations, and other services. I agree to pay for these services even if they are deemed not "medically necessary", are "non-covered", or are "bundled" by Medicare, Medicaid, Blue Cross, or any other insurer. I authorize the Pediatric Clinic to file my insurance claims to clear any unpaid balance on my account and assign benefits payable to Pediatric Clinic or to the physician. I am aware that I may be charged a $50 fee for missing an appointment (or failing to cancel with at least 2 hours notice) that will not be covered by my insurance. I understand that the fee(s) charged are due at the time of service, including all deductibles and co-payments. If I have an unpaid balance I agree that I will be responsible for a monthly statement fee of $15. I, the undersigned, accept the fee(s) charged as a legal and lawful debt, including any previously owed balances. Additionally, I agree to be responsible for any costs that may be required to satisfy any of the unpaid debt with Pediatric Clinic, or our collection agency in accordance with state and federal law, including billing fees, collection agency fees, attorney fees, and court costs. Should it be necessary to forward my account to a collection agency, I agree to pay all monies due, plus a 35% collection agency fee in addition to court costs and attorney fees if such be necessary. I waive now and forever my right of exemption under the laws of the Constitution of the State of Alabama or any other state. I also agree to pay a $30 worthless check fee for any checks returned FOR ANY REASON plus reimburse the Pediatric Clinic for the original check amount in cash or other certified funds. I agree to be responsible for acquiring all necessary referrals.

I agree to the terms of service as stated above

Electronic Signature - By signing below I agree to the terms of service listed above

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