CONSENT FOR EXAMINATION, MEDICAL TREATMENT AND CONDITIONS OF EXAMINATION.
Consent is hereby given to perform any and all examinations, tests, procedures, and treatments necessary and/or advisable; and in an emergency, without the presence of parents or responsible adults. I hereby authorize examination and treatment of the above named patient by the physicians and physician extenders employed by Preferred Medical Group. I realize that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me as to the result of treatments or examination in this practice.
INFORMATION CONCERNING FILING A CLAIM WITH YOUR INSURANCE COMPANY.
If we participate with your primary insurance, Preferred Medical Group will gladly file a claim for you. We will allow your insurance company up to 45 days from the date of service to pay the claim. If your insurance company fails to fully compensate Pinnacle Enterprises PC dba Phenix City Children’s & Family Clinic, Fort Mitchell Clinic PC and/or or Opelika Pediatrics & Family Clinic PC within this time frame, any unpaid balance becomes your sole responsibility.