1) I hereby give authorization for payment of insurance benefits to be made directly to Grace Pediatrics. This authorization will be good for one year.
2) I understand that I am financially responsible for all charges whether or not they are covered by my insurance company. In the event of default, if this account is assigned to an attorney, collection agency, or small claims court, the prevailing party shall be entitled to reasonable attorney's fees and cost of collection.
3) I authorize this office to release all information necessary including medical records to secure payment of benefits for all services rendered to me.
4) I further agree that a photocopy of this agreement shall be valid as the original. I understand that I have the right to withdraw this authorization by written consent at any time.
5) Return check policy: for all returned checks, we will charge a $35 fee that will not be paid by your insurance company.
NO SHOW POLICY: If you are unable to keep your appointment, please give a 24 hour notice of cancellation, otherwise a no show fee of $30 for new patients and $20 for established patients will be incurred. This will not be paid by your insurance company and payment is expected at, or by time of your next office visit.
I have read and understand the above.
