Child's Date Of Birth
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I request payment of authorized benefits be made to the above-named facility on my behalf, for any services provided to me or my child. I authorize any holder of medical and other information about me or my
child to release to an insurance company, any other third-party payer, state medical assistance agency, or any other governmental or private pay are responsible for paying benefits, any information needed to determine these benefits or benefits for related services. I authorized a copy of this authorization to be used in place of the original.
I agree to pay for All Charges not covered by a third-party payer (insurance company).
Should be Empty: