Kids & More Pediatric Care, P.A.
Robert M. Friedmeyer, M.D., F.A.A.P.
302 Bryan Rd. Suite #1
Brandon, Fl. 33511
Office: (813) 654-1220
Fax: (813) 654-6746
PRIMARY INSURANCE
Name and address of Insurance Carrier_______________________________________________
Policy Holder___________________________________________________________________
Policy Number__________________________________________________________________
Group Number__________________________________________________________________
SECONDARY INSURANCE
Name and address of Insurance Carrier_______________________________________________
Policy Holder___________________________________________________________________
Policy Number__________________________________________________________________
Group Number__________________________________________________________________
I hereby authorize Robert M. Friedmeyer MD FAAP to release to my insurance carrier
any information acquired in the course of my examination or treatment, including the
diagnosis and records.
Signature___________________________________________________
I hereby authorize payment directly to Kids & More Pediatric Care, Inc. of the medical
and/or surgical benefits otherwise payable to me, not to exceed the charges made for such
treatment. I understand that I am financially responsible for the charges not covered by
my insurance.
Signature___________________________________________________
I understand that if my account is turned over to a collection agency for non-payment, I
will be charged an additional fee to cover the costs of recovery. I also understand there
will be an additional charge for returned checks.
Signature___________________________________________________
Date_______________