*I acknowledge and understand the office policies and procedures explained above and have received a copy. I hereby authorize my insurance companyto pay El Paso Pediatric Associates, PA directly. A copy of this authorization can be considered an original for insurance purposes.
*I do hereby consent to and authorize the performance of all examinations, treatments, and medical services by El Paso Pediatric Associates, PA and theirstaff, which may be deemed advisable. My signature on this document indicates that I have read, understand and agree to the policies outlined in this document