Insurance Authorization

By signing this form, you acknowledge that you have or will contact your insurance company to verify that Lakeview Pediatrics, LLC is under contract and in network with your insurance company, listed below.
 
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Insurance Authorization
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Patients Covered By Insurance
Name of patients covered by this insurance policy:*     Date of birth:*

I understand that all copays are due at the time of service and that all balances are not paid by insurance are my responsibility.
Parent Signature
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