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Declaration of Insurance

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Child's First Name

Child's Last Name

DOB

Dear Parents and Guardians,

We understand that changes in insurance coverage can occur, and your child may now be enrolled under a new or different policy. If your child has recently been added to your insurance plan or has new active coverage, please complete the attached form in its entirety.

As a courtesy, our office will submit claims for your child’s previous visits to the commercial insurance you provide on this form. This documentation may also be used to confirm your request for us to bill your insurance retroactively.

Important Note for HMO Members:
If your child is covered under an HMO plan, Gold Star Pediatrics must be designated as the Primary Care Provider (PCP) for claims to be eligible for coverage. Before submitting this form, please contact your insurance company and request that either Gold Star Pediatrics (NPI: 1669129342) or Dr. Patel (NPI: 1003082280) be listed as your child’s PCP, effective from the earliest date you wish to have visits covered.

For in-network insurance plans, please allow 30 to 90 days for claim processing by your insurance provider. Once processed and returned to our office, any necessary billing adjustments and applicable refunds will be issued to the address we have on file.

If you have an HMO plan, is Dr. Patel the primary care provider listed on the insurance plan? NPI 1003082280

You understand that the insurance may take 30 to 90 days to process the claim. Once the EOB is in our office, our biller will adjust the account and issue any refunds owed. Any non-covered proceedures or visits will be deducated from the refund before refund is issued.

I allow Gold Star Pediatrics to bill my insurnace plan for the prior visits my child has had within the last year (12 months).

Insurance Name

Policy Number

Subscriber Name:

Medicaid: You understand we are NOT in network with all medicaids. We can only bill Sunshine, Humana, and/or Molina. Child must have their own medicaid number.

Medicaid ID Number

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Your Signature: I agree to the terms and conditions above, as incorporated herein. I understand it is up to my insurance company to cover my visits. I allow Gold Star Pediatics to bill my insurance. I understand if I have HMO planI must have Dr. Patel or Gold Star Pediatrics as my child's PCP for the visits to be covered.

DATE SIGNED