I acknowledge that Texas Family Pediatric Group provided me with the Notice of Privacy Practices. I give permission for my protected health information to be used by Texas Family Pediatric Group and disclosed to others for the purposes of treatment, obtaining payment, or supporting the day to day health care operations of the practice. I understand that I may request restrictions on the use or disclosure of my protected health information and that if Texas Family Pediatric Group agrees to this request, the restriction will be binding on the practice. I further understand that I may revoke, in writing this consent to use and disclose protected health information.

1. That the responsible party will make immediate payment for services rendered; If Texas Family Pediatric Group is contracted with your insurance company, payment is due immediately on co-pays, non-covered services and co-insurance.

2. That it is the responsibility of the policy holder to familiarize themselves with their insurance policy, and its benefits and limitations.

3. That I authorize payment of medical benefits to Texas Family Pediatric Group for services rendered. I also understand that ultimately I am financially responsible to Texas Family Pediatric Group for all charges whether or not covered by my insurance carrier.