Common Contracts
1 similar Office Financial Agreement contracts
Myrtle Avenue Pediatrics 2019 Office Financial AgreementOffice Financial Agreement • September 13th, 2021
The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical insurance status. I certify that my child has health insurance currently in force as detailed above. I assign directly to Myrtle Avenue Pediatrics all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I herby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic. I, the undersigned, agree to be financially responsible.
