Patient Demographics

I request that payment of authorized Medicaid and/or commercial insurance bene! ts be made to Fairhope Pediatrics, Inc. for any service furnished to me or my dependent by Fairhope Pediatrics’ providers. I authorize Fairhope Pediatrics, Inc. to release medical information which may be required by my insurance carrier to determine payment for services rendered. I further understand that I am responsible to pay certain amounts due the physician. These amounts could include annual deductibles, copayments, charges denied as not covered by Medicaid or my commercial insurance carrier, and charges denied for services determined as not medically necessary. I further understand that if Fairhope Pediatrics, Inc. incurs any fees associated with collecting reimbursement on my account, I will be responsible for paying all of those fees.