New Web User

Insured: Parent: Legal Guardian:

By clicking this box, you acknowledge the following:

(1) I am the father, mother, or duly appointed guardian of the above-named insured (the “insured”) with full parental rights and authority to view medical claims on behalf of the insured;

(2) the insured is currently under the age of eighteen (18);

(3) on the day the insured reaches age eighteen (18), claim access is revoked;

(4) I am responsible for all liability resulting from access hereto or resulting from giving or obtaining healthcare information on behalf of the insured through this site; and

(5) I hereby indemnify Administrative Concepts, Inc. from all damages related to my use of this site.