*I authorize payment of benefits directly to Drs. Gordon A. Price & Associates for services rendered. I also authorize release of any medical information that may be required in determination of such benefts.
*I understand that some services may require approval of my child's primary care physician for coverage and that, if I don't obtain that approval, I am financially liable for the services.
*I understand that my insurance carrier may not cover some services and products and benefit information does not constitute approval of payment. Deductibles & fees not paid by my insurance carrier will be my responsibility.
*I acknowledge that I received a copy of Drs. Gordon A. Price & Associates "NOTICE OF PRIVACY, HIPAA" policy.