I authorize Northpointe Pediatrics, P.C. to evaluate and treat my child/children and to release to our insurance company any information acquired in the course of my child’s examination or treatment, and to receive all payments for such examination or treatment. Northpointe Pediatrics, P.C. has my permission to release any diagnostic studies, report, etc. to a specialist involved in caring for my child.
I understand that a parent/legal guardian must be present for my child’s well visits. If this is not possible and someone else must bring my child, a written authorization with the parent/legal guardian’s contact information will be provided and all insurance co-payments will be made.
All information that I 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 status. I understand and agree to the terms of the above financial policy.
I assign directly to Northpointe Pediatrics, P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I acknowledge that I have been offered a copy of Northpointe Pediatrics, P.C. “Notice of Privacy Practices”
I authorize the use of this signature on all my insurance submissions whether manual or electronic.