Please Note: this office does not do third party billing to ex-spouses or other individuals. Whichever parent/guardian brings the child to the office is responsible for any outstanding deductibles, co-payments, co-insurances, or bills due to lapses in insurance coverage. There are no exceptions.
I authorize payment of medical benefits to the physician or supplier of PEDIATRIC ASSOCIATES OF NORWOOD AND FRANKLIN, P.C. for services rendered during my child(ren)'s examination and/or treatment. I also authorize my child(ren)'s physican to release any information acquired in the course of their examination and/or treatement to my insurance company to determine these benefits or the benefits payable for related services.
By signing below, I indicate that I have read and understand all the information on this form. Any information that I have entered is, to the best of my knowledge, correct.