You may access the following form to assist us with your care. Please complete the following form, and click the "Submit" button at the bottom of the form.
*We are committed to keeping your personal information secure. All of our online forms are submitted via a secure connection and are HIPAA compliant.
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.
I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
I understand that where appropriate, credit bureau reports may be obtained.