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Modesto Pediatrics Financial Agreement and Consent (2016) We are committed to providing your family with the best possible pediatric care. Your signature at the end of this document will indicate
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How to fill out the Modesto Pediatrics Financial Agreement:

01
Begin by obtaining the Modesto Pediatrics Financial Agreement form. You can usually find this form on their website or request a copy from their office.
02
Carefully read through the entire agreement to understand the terms and conditions. Make sure you understand each section and any payment responsibilities mentioned.
03
Provide your personal information such as your full name, address, phone number, and email address in the designated fields on the form.
04
If applicable, include the name of the patient for whom you are filling out the agreement. This could be your child's name if you are a parent or your own name if you are the patient.
05
Indicate the primary insurance information, including the name of the insurance company, policy number, and group number. If you have secondary insurance, provide the necessary details as well.
06
If you have any specific instructions or requirements regarding the billing and payment process, make sure to communicate them clearly in the provided section of the agreement.
07
Sign and date the financial agreement form to acknowledge that you have read and understood the terms and agree to comply with them.
08
Return the completed form to Modesto Pediatrics by either submitting it online, mailing it to their office, or personally dropping it off.
09
Keep a copy of the filled-out financial agreement for your records.

Who needs the Modesto Pediatrics Financial Agreement?

01
Parents or legal guardians of patients under the age of 18 who will receive medical services from Modesto Pediatrics.
02
Adult patients who will receive medical services from Modesto Pediatrics.
03
Individuals who seek consultations, treatments, or any other medical services from Modesto Pediatrics, regardless of age.
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The Modesto Pediatrics financial agreement is a document outlining the terms and conditions regarding payment for medical services provided by the clinic.
All patients are required to sign the Modesto Pediatrics financial agreement before receiving medical services.
To fill out the Modesto Pediatrics financial agreement, patients must provide their personal information, insurance details, and agree to the payment terms.
The purpose of the Modesto Pediatrics financial agreement is to establish clear expectations regarding payment for medical services and to ensure that patients understand their financial responsibilities.
The Modesto Pediatrics financial agreement must include patient's personal information, insurance details, and agreed upon payment terms.
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