Patient Financial Information Sheet
I understand that payment in full is due at time of service unless other arrangementshave been made.
I understand that I am responsible for any insurance deductible, copay, andnon-covered services:
Authorization and Release:
I authorize the release of any information including the diagnosis and the records of anytreatment or examination rendered to my child or me during the period of such care to thirdparty payers and/or other health practitioners.
I authorize and request my insurance company to pay directly to the doctor, insurance benefitsotherwise payable to me.
I authorize the release of any information regarding my care to: