Financial Agreement

In order to obtain reimbursement for services provided to my child by Northpoint Pediatrics, I authorize disclosure of my child’s record for treatment, payment, and healthcare operations.

If my primary care physician is a participating provider in my insurance plan, I hereby assign medical benefits due be paid directly to Northpoint Pediatrics. 

"I/we hereby designate Northpoint Pediatrics and its employees as my/our representative to file grievances and to represent me/us in accordance with the Indiana Code, Title 27, Chapters 8 and 13." 

I understand that I am financially responsible for any balances not paid by my insurance carrier within 60 days from the date the services. If the patient fails to provide proof of insurance within 60 days, the patient is responsible for the balance in full. If no Secondary Insurance information is provided, I attest and affirm that I have no other insurance other than that listed as Primary Insurance.

I understand that if my child’s account becomes delinquent it will be assigned to an attorney for collection and/or suit, and the prevailing party shall be entitled to reasonable attorney’s fees and cost of collection fees equal to 30% of the delinquent balance.  I also understand that my family will be asked to seek medical care elsewhere.

This assignment will remain in effect until revoked by me in writing. A photocopy of the assignment is to be considered as valid as the original.

 

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Guarantor Signature  

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Date                                                                                                      

 
Young brothers