subject_line
Patient Name
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DOB
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Primary Insurance Company
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Phone number of Insurance Company
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Policy Holder Name
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Relationship to Patient
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Policy Number
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Group Number
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Employer of Policy Holder
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Policy Holder SSN
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Policy Holder DOB
*
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Does this insurance company allow in house labs to be performed?
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Which laboratory does insurance prefer for send out labs?
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Secondary Insurance Company
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Phone number of Insurance Company
*
Policy Holder Name
*
Relationship to Patient
*
Policy Number
*
Group Number
*
Employer of Policy Holder
*
Policy Holder SSN
*
Policy Holder DOB
*
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Does this insurance company allow in house labs to be performed?
*
Which laboratory does insurance prefer for send out labs?
*
Does your insurance cover immunizations?
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I understand that it is my responsibility to know which services my insurance plan covers, and if the information I provide is incorrect, I will be responsible for payment for charges.
Signature
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clear
Relationship to Patient
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Date
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Authorization to Release Information and Assignment of Benefits
I hereby authorize the release of medical information necessary to file a claim with my health insurance company, and I authorize the assignment of benefits, otherwise payable to me. to Kids First Pediatrics of Georgia. I understand that I am financially responsible for payment for services rendered which are not covered by my insurance company.
Signature
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clear
Relationship to Patient
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Date
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Authorization for Additional Charges
I understand and agree that there will be a returned check fee of $30.00. If my account is turned over to a collection agency, I will be responsible for all collection fees. If legal action is taken to collect my debt I will be responsible for all attorney fees and court costs. I understand that if an account has been sent to a collection agency, all balances must be paid in full before any future appointments can be scheduled.
Signature
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clear
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