Patient Information Form Page 5
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IB
-
.
"Personal Doctor For Your Child"
ANDREW
M. BLUMBERG, M.D.
PEDIATRICS· INFANTS, CHILDREN AND ADOLESCENTS
OFFICE
POLICY
AND ELIGIBILITY WAIVER
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ understand I am eligible
(Parent Name)
for
as
of·
- - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - -
(Name of Health Plan)
through
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(Employer)
(Effective Date)
I have chosen Andrew M. Blumberg, M.D., as the provider of my child's health care. I
understand it is customary for the insurance company to process the claim within 30 -
45 days of the date of filing, but I understand that if I am found
to
be
ineligible,
I am
ultimately responsible
for payment in full to Andrew M. Blumberg, M.D., for services
rendered.
If
the insurance company should fail to pay the claim within 45 days
,
whether
or
not
covered
by the
insurance, I understand Andrew M. Blumberg, M.D. may collect
the amount of the claim from me directly.
Patient Name - (Please Print)
Parent or Guardian - (Please Print)
Parent
or Guardian
-
(Signature)
Witness
Date
Sand Canyon Medical Center
16100 Sand Canyon Avenue, Suite 350
• Irvine,
California 92618
Tel
:
(949) 450-0077 •
Fax:
(949) 450-1277
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