Common Contracts
1 similar Office Financial Agreement contracts
ContractOffice Financial Agreement • November 22nd, 2020
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 Lori McAuliffe, M.D., P.A. 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 hereby 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:
