Departing Patients Release Form

  • AUTHORIZATION TO RELEASE MEDICAL INFORMATION

    I hereby authorize St. Clair Pediatrics to release any information acquired in the course of my examination or treatment to any insurance company against which claims are filed on my behalf. I hereby authorize any insurance payments paid directly to St. Clair Pediatrics, LLC for medical benefits, if any, and otherwise payable to me for services rendered. I understand that I am responsible for payment of all charges for services rendered and that if my insurer fails to pay any portion of these charges for any reason, I will be responsible for all sums due St. Clair Pediatrics. If my account is sent to an attorney or collection agency, I will be responsible for any collection fees and/or court costs. A copy of this signature is as valid as the original.
  • Date Format: MM slash DD slash YYYY

What Our Families Are Saying

Hollie H.

Dr. Garrison and his staff are just the best!!!! I could not ask for a better pediatrician for my son!! I would highly recommend them to anyone! 

Catrina H.

We just switched to them and I’m so glad we did! The office is beautiful and clean and everyone there is very friendly and helpful.

Karen R.

As stressful as it can be to bring your sick child into the pediatrician’s office, the staff at St. Clair Pediatric’s always know how to provide a calm & comforting environment! The care provided by their staff is nothing short of spectacular.