PATIENT INFO

PARENT/ GUARDIAN INFO

INSURANCE INFO/ RESPONSIBLE PARTY

EMERGENCY CONTACT INFO (not living with patient)

I hereby assign the benefits from any insurance or third party to GENTLE PEDIATRICS PLLC for medical services provided to my child. I understand that GENTLE PEDIATRICS PLLC has the right to decline or accept assignment of such benefits. If these benefits are not assigned to GENTLE PEDIATRICS PLLC, I agree to forward to the practice, upon receipt, any insurance or third-party payments I receive for services rendered to me. I authorize the release of any medical information needed to determine the benefits. This authorization will remain valid until I revoke it by written notice. I understand that I am financially responsible for all charges whether or not they are covered by insurance.