Patient Financial Information Sheet

I understand that payment in full is due at time of service unless other arrangements
have been made.

I understand that I am responsible for any insurance deductible, copay, and
non-covered services:

Authorization and Release:

I authorize the release of any information including the diagnosis and the records of any
treatment or examination rendered to my child or me during the period of such care to third
party payers and/or other health practitioners.

I authorize and request my insurance company to pay directly to the doctor, insurance benefits
otherwise payable to me.

I authorize the release of any information regarding my care to: