Pediatric Registration Form

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Patient Information

Insurance Information

Primary Insurance Information

Secondary Insurance Information

Patient/Legal Guardian Information

Emergency Contact Information

Acknowledgement of Financial Agreement

Responsibility for Payment I acknowledge that acceptance of my insurance information is not a guarantee of payment by my health plan until the claim has been accepted and processed. I further understand that if my claim is not accepted for payment I am personally responsible for payment of medical services rendered to me. Responsibility for Co-Payments I agree to pay all applicable health plan co-payments at the time of service. I understand that if (1) I do not pay my co-payments at the time of service, and if (2) an office billing statement is subsequently generated, I will be responsible for making full payment of any unpaid balance. Payment Due Date I understand that all health plan deductibles and charges for non-covered benefits are due and payable upon presentation of a billing statement from UR Health Medical Centers, Inc. UR Health Medical Centers, Inc. sends billing statements for services rendered to a minor child under the age of 18 to the insurance Subscriber. All co-payments for minor children must be paid at the time of service by the parent/guardian who accompanies the child on the visit to the pediatrician. PATIENT OR AUTHORIZED PERSON’S SIGNATURE. I acknowledge that I have read the above payment policies of UR Health Medical Centers, Inc and abide by them I further authorize the release of any medical or other information necessary process this claim.

For Office Staff Only

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