I affirm that the above information I have provided is correct to the best of my knowledge. It will be held in the strictest of confidence in this office and it will be by responsibility to inform this office of any changes in my medical status. I also authorize the release of any information concerning my (or my child"s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor. I, the patient and/or responsible party listed below hereby agree to pay all charges submitted by this office during the course of treatment for the patient. I furthermore agree to pay all applicable co-payments, deductibles, and/or treatment rendered to me or the patient which is not considered to be a covered service by third party insurers or payers. In the event that I do not have insurance, I understand that all charges are payable to day of service unless payment arrangements are made in advance with the office staff.