Automatic Insurance Claim Submission

PATIENT INFORMATION

Please complete and list all children in your family:

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PARENT/GUARDIAN INFORMATION
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PAYMENT RESPONSIBILITY
Payment Responsibility:

As a service, Riverside Pediatrics will submit claims to most insurance carriers, if provided with policy numbers, address and any other patient information needed.

I understand that I assume responsibility for any deductible, current co-payment or other balance not covered by my insurance carrier.

I have read the above and accept that I am financially responsible for all charges whether or not paid by my insurance.

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Patient Financial Responsibility *:

AUTHORIZATION
Authorization:

I authorize Riverside Pediatrics to release any medical information including diagnoses, x-rays, test results, reports, and records pertaining to any treatment or examination rendered. I understand that this medical information may be used for any of the following purposes: Diagnostic, insurance legal, and when the provider deems necessary to ensure the best medial care for the patient. I further understand that any persons that receive these medical records will not release any of the medical information obtained by this authorization to any other person or organization without a further authorization signed by me for release of information.

I authorize the release of any medical information necessary to process claims. I authorize Riverside Pediatrics to submit claims to my insurance company on my behalf and my insurance company to pay them directly. I permit a copy of the authorization to be used in place of original. This authorization may be revoked by me at any time in writing.

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Parent/Guardian Authorization *:

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FIND US

843-833-8595

435 Marina Drive
Georgetown, SC 29440

Directions

Office Hours

MONDAY – FRIDAY
8:00 AM – 5:00 PM
SATURDAY
8:00 AM – 10:00 AM

843-401-4200

402 Nelson Boulevard
Kingstree, SC 29556

Directions

Office Hours

MON, WED, THUR, FRI
8:00 AM – 5:00 PM
TUESDAY
8:30 AM - 5:00 PM
SATURDAY
Closed

RECOGNITIONS

American Board of Pediatrics American Academy of Pediatrics NCQA Patient-Centered Medical Home
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