CURRENT LEGAL GUARDIAN/EMERGENCY CONTACT
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 govermental 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 tp pay for ALL Charges not covered by a third-party payer (insurance company).
As a patient of Excellent Pediatrics, I understand and acknowledge the following:
For more information contact us on 678-807-2230 or the Office of Civil Rights on 404-347-3125