(Medical Information may be released to this contact)
(Kindly accept the following terms and conditions before submission of forms)
The above information is true to the best of my knowledge. I
authorize my insurance benefits be paid directly to JB Healthcare
LLC d/b/a Little Star Pediatrics. I understand that I am
financially responsible for any balance. I also authorize JB
Healthcare LLC d/b/a Little Star Pediatrics or my insurance
company to release any information required to process my claims.
I authorize the medical providers of JB Healthcare LLC d/b/a
Little Star Pediatrics to view and obtain my child’s external
prescription history via electronic prescription services. I
understand that prescription history from multiple other
unaffiliated medical providers, insurance companies, and pharmacy
benefit managers may be viewable by my providers and staff through
these services, and may include prescriptions back in time for
I certify that I have received a copy of Notice of Privacy
Practices. The Notice of Privacy Practices describes the types of
uses and disclosures of my child’s protected health information
that might occur in my treatment, payment of my bills or in the
performance of JB Healthcare LLC d/b/a Little Star Pediatrics .
The Notice of Privacy Practices also describes my child’s rights
and JB Healthcare LLC d/b/a Little Star Pediatrics’ duties with
respect to my child’s protected health information. The Notice of
Privacy Practices can also be found on theJB Healthcare LLC d/b/a
Little Star Pediatricswebsiteat littlestarpeds.com. JB Healthcare
LLC d/b/a Little Star Pediatrics reserves the right to change the
privacy practices that are described in the Notice of Privacy
Practices. I may obtain a revised Notice of Privacy Practices by
calling the office and requesting a revised copy be sent in the
mail, asking for one at the time of my next appointment, or
accessing the practice website
Kindly check again if you have entered the correct details before submission. No correction from this point forward.
At the submission of this form, we will contact you shortly, or you could check-in at our clinic. The generated form would be sent to your given email address.