Insurance Information / Financial Responsibility

Insurance Company Name:                                                                                          

Policyholder’s Name and Employer:                                                                              

Is there secondary insurance?:                Yes               No   

Insurance Information / Financial Responsibility

As a health insurance policy holder, you are part of a complex insurance network with multiple and varying benefits.  You have chosen Indianapolis Independent Pediatricians, P.C. (IIP) to provide appropriate and comprehensive medical services to your child(ren).  Unfortunately, some procedures IIP feels are medically necessary for optimal treatment of illness and/or preventative care for our patients are not covered by some insurance plans.  This may include, but is not limited to, peak flows, tympanograms, aerosol treatments, immunizations, hearing screens and ear wicks. 

Due to the differences in various insurance plans and programs, IIP cannot guarantee that the services provided by our practice will be covered by your insurance policy.  In addition, our practice may or may not have a preferred provider agreement with your specific insurance program.  It is your sole responsibility to know and determine what medical services your health policy includes and excludes, and which hospitals, laboratories, x-ray facilities and other medical facilities are acceptable and covered by your insurance policy.  Therefore, before providing your child(ren) with medical services, IIP requires that all parents or guardians sign this form accepting financial responsibility for any and all services provided by IIP regardless of whether such services are covered by your particular insurance program.

Consent

As a parent or guardian seeking medical services for                                           , I have read the above explanation regarding my financial responsibility for my child(ren)’s medical services and hereby agree to assume full financial responsibility for any and all medical services provided by IIP regardless of whether such services are covered by my insurance program.  I understand that I am fully responsible for knowing and determining what services my insurance program includes and excludes.  I further understand that I am fully responsible for providing IIP with new insurance information immediately, and realize I may be billed in full for any medical services if I fail to do so.  I further authorize IIP to release any medical information to my insurance company necessary to process our claims.  In the event IIP has to pursue a collection action against me, I understand that in addition to my financial responsibility for the medical services provided, I will be responsible for all costs and attorney fees associated with such collection.

Signature of Parent / Guardian                                       Printed Name

                                                                                                                                               Date                                                                             Relationship to Patient