I understand that payment of all medical care is due at the time of service. In case of divorced parents, responsibility andpayment shall be that of the guardian bringing the child in for treatment. I understand that it is my responsibility to pay anydeductible, co-insurance, or any other balance not paid by my insurance company. I understand that I am responsible for anycost incurred in the collection of patients account in case of default, including reasonable attorney fees and court cost. Iagree to pay any deductibles and any amount not covered by Insurance.
I understand that it is my responsibility to call the office to cancel/reschedule any Well Visits/Yearly Physical, 24 hoursbefore the scheduled appointment. Failure to do so will result in a “Missed Appointment” fee of $15 per appointment. Copiesof Vaccination Forms (3231) and Hearing/Vision/Dental Forms (3300) after the Annual Physical will cost $5 per form.I understand that insurance companies have agreements with certain laboratories for lab work and that it is my responsibilityto know which laboratory my insurance authorizes and to inform the staff of Sugarloaf Pediatrics as to which laboratory myinsurance covers.
I hereby grant permission to Sugarloaf Pediatrics to release any pertinent information to my insurance company upon request,and I also assign and authorize payment directly to Sugarloaf Pediatrics. A photo copy of this authorization shall beconsidered as effective and valid as the original.
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