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PLEASE PRINT AND COMPLETE THIS FORM.
BRING IT TO YOUR CHILD’S FIRST VISIT OR FAX IT TO THE
OFFICE AT
860-232-2750.
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Child’s
name
__________________________________________
Date
of Birth
___________________________
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I, the undersigned, do hereby
authorize Howard G. Smith, M.D. and other staff of Pediatric
Ear, Nose & Throat Associates, P.C. to provide treatment
for the above noted minor child.
I furthermore authorize Dr. Smith and the staff of Pediatric
Ear, Nose & Throat Associates to submit on my and my
child’s behalf claims for reimbursement to the
appropriate insurance company or managed care organization.
I understand that such claims will contain some protected
health information.
SIGNED:
_____________________________________
Relation to
patient:
_____________________
Date:
_______________________
Thank
you for taking the time to complete this form.
We are looking forward to meeting you at your
child's first visit.
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© 2010 Howard G.
Smith MD
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