Guarantor Forms

I have read and understand West Phoenix Pediatrics, PLC’s Financial and Office Policy, and agree to abide by its terms. This signature authorizes our office to treat my child and file appropriate insurance claims.

I agree to be financially responsible for any charges not covered by insurance.

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

Signature

Print Name

Date

Guarantor’s Address

City

State

Zip

Phone Number:

Staff member

(initals)

verbally verified above Guarantor at

(phone number)

Date

Person listed is financially responsible Guarantor for all patients on this registration form.
Unpaid balances will be sent to a collection agency. If the above Guarantor declines financial responsibility then I agree to be financially responsible.

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

Signature

Print Name

Date

Office use only:

Version

Copy given to Parent/Guardian by:

Your information will be encrypted.