A Smile 4 U - Jordan Diaz

I understand that i am financially responsible for

Info iconThis preview shows page 1. Sign up to view the full content.

View Full Document Right Arrow Icon
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: e benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. A Smile 4U may use my child’s health care information and may disclose such information to the above-named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. ___________________________________________________________________ Signature of Parent, Guardian or Personal Representative ___________________________ Date Rebekah Naomi Diaz ___________________________________________________________________ ____________________________ Please print name of Parent, Guardian or Personal Representative Date PLEASE COMPLETE BOTH SIDES 07/2013 PATIENT MEDICAL HISTORY Josephine Ediale 770-459-9378 Patients Physician: Nam...
View Full Document

This note was uploaded on 01/28/2014 for the course ITMG 321 taught by Professor Krueller during the Fall '11 term at American Public University.

Ask a homework question - tutors are online