This policy describes the routine uses and disclosures of the patient's protected health

information.  It also includes your health policy rights. 

Fill information for the children you want to register to be patients of Wishing Well Children's Clinic.

This agreement allows Wishing Well Children's Clinic to file a claim to your insurance for the services rendered.

This is to acknowledge that we have shared the Notice of Privacy Policy.

Provide information of your child's previous doctor to enable us to obtain his/her previous medical records.

This form is to acknowledge that your insurance may not cover some of the services performed.  Any services provided that are not covered will go to patient responsibility.