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Newborn Insurance Waiver

Newborn Insurance Waiver

The following waiver is intended for newborn patients, equal to or less than 30 days old. Insurance is due for newborns no later than the 31st day of life. If you are unable to provide active coverage on or after the 31st day of life, you will be responsible for the payment of any costs you have incurred thus far.

Newborn Self-Pay Estimates

Newborn Check: $122.50*

Follow Up: $112.00*

Sick Visit: $133.00*

** The totals above are just an estimate of the cost of care and may differ from the exact amount owed after services have been rendered. **

First and Last
Patient Date of Birth
First & Last Name
Today's Date

Revised 12/01/2020

* Required field