Patient Information

 

Parent/Guardian

 

Insurance/Guarantor

 

Electronic Signiture

    Electronic Signiture

  • As the adult accompanying the child to Night Light Pediatrics P.A., I assume responsibility for all professional fees and facility charges incurred during this visit. I understand that payment is due at the time of service*. In the event that the above identified insurance company does not make appropriate payment, I will be responsible for the balance of the charges incurred.
  • *Payment of copays is expected at the time services are rendered for patients who have contracted insurance. Verify with the front desk which plans are accepted.
 

Verification