Patient Details

PATIENT REGISTRATION


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Siblings Name Age Sex

                           

Assignment and Release of Information:

I, the undersigned, certify that I (or my dependent) have insurance coverage with the above insurance company and assign directly to Pediatric Healthcare of Northwest Houston, PA all insurance benefits if any, otherwise payable to me for services rendered. I understand I am fully responsible for all charges whether paid or not by the insurance company. I hereby authorize Pediatric Heal thcare of Northwest Houston, PA to release all information necessary to secure the payment of benefits. I authorized the use of this signature on all insurance submissions.



Notice of Privacy Practices and Consent to Use and to Disclose Protected Health Information:

Your protected health information will be used by Pediatric Healthcare of Northwest Houston, PA or disclosed to others for the purposes of treatment, obtaining payment, or supporting day-to-day healthcare operations of the practice. Pediatric Healthcare of Northwest Houston, PA reserves the right to modify the privacy practices outlined in the privacy notice. Notification will be served upon a change. I have reviewed the brochure “Notice of Privacy Policies and Practices” and give my permission to Pediatric Healthcare of Northwest Houston, PA to use and disclose my health information in accordance with this consent and the notice provided.