UPDATE - Consent to Treat - Financial Information

Patient Name

Patient Date of Birth

Address

City

State

Zip

Confirmation of Insurance

By signing below, I confirm that the insurance information currently on file in the patient record is up to date and valid. I further agree to advise Bloomington Pediatrics immediately of any changes to my insurance coverage.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Responsibility for Payment for Services Rendered

By signing below, I authorize Bloomington Pediatrics, LTD to submit claims for services rendered to the insurance company/companies listed by me. I authorize the release of protected health information to said insurance companies for the processing of claims. I understand that I am responsible for payment of services rendered and agree to pay any fees for services not covered by insurance, including, but not limited to coinsurance and deductible amounts. I agree to pay at the time of service any co-payment required by my insurance. I also understand I will be held responsible for the payment of any collection fees should my account be sent into collection proceedings.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Consent to Medical Treatment

By signing below, I consent to and authorize the physicians, nurses and other healthcare providers at Bloomington Pediatrics, LTD to perform appropriate healthcare examinations, treatment, diagnostic testing or medication administration as deemed medically necessary by their professional judgment. I know that there are some risks with all medical treatments and procedures and I understand that no one can guarantee how well treatments or procedures will work.

In addition to the legal guardians of the patient, the persons below are authorized to schedule and/or accompany the patient to their appointments, consent to recommended medical care, and receive health information about the patient. This consent will expire upon the patient’s 18th birthday, at which time a new consent must be signed.

Name

Relationship to Child

Add new row for another legal guardian or authorized adult

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.