I authorize (Clinician Name) to release billing/medical information which may include client(s) name(s), date and type of services, diagnoses codes, substance abuse information, treatment and/or any other information needed to my insurance company/ies for the purpose of: Collecting insurance benefits, obtaining coverage information or for authorization of additional sessions for:
Client Full Name Date of Birth
Client Full Name (if additional) Date of Birth
Signature of Client or Legal Guardian Clear Date Witness Date Primary Insurance Information Insurance Company Name Client Name Insurance Company Address Policy Holder’s Name Insurance Company Phone Number Policy Holder’s Address Policy Number or Member ID Policy Holder’s Date of Birth Group Number (if applicable) Co-Pay Secondary Insurance Information Insurance Company Name Client Name Insurance Company Address Policy Holder’s Name Insurance Company Phone Number Policy Holder’s Address Policy Number or Member ID Policy Holder’s Date of Birth Group Number (if applicable) Co-Pay ** Clinicians will need to photocopy of insurance card(s) NOTE: Although your insurance MAY cover most of your fees, ultimately it is your responsibility to cover all your costs. Some plans require preauthorization before your first visit. It is your responsibility to obtain this authorization. It is also your responsibly to know what your benefits entail, your eligibility, co-pay and any deductibles that you may have. Mental Health benefits may differ from your medical benefits so it is essential that you have researched your mental health benefits prior to your visit. If you have not done this prior to your visit, and/or your treatment is not a payable benefit, you will be responsible for the full cash payment at the time of service. Further, if your insurance carrier determines that the services received are not medically necessary, you will be responsible for full payment of your accrued fees. Re-Disclosure: I understand that once my health care provider discloses my health information to the recipient identified above, my health care provider cannot guarantee that the recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
Witness Date
Insurance Company Name Client Name
Insurance Company Address Policy Holder’s Name
Insurance Company Phone Number Policy Holder’s Address
Policy Number or Member ID Policy Holder’s Date of Birth
Group Number (if applicable) Co-Pay
** Clinicians will need to photocopy of insurance card(s) NOTE: Although your insurance MAY cover most of your fees, ultimately it is your responsibility to cover all your costs. Some plans require preauthorization before your first visit. It is your responsibility to obtain this authorization. It is also your responsibly to know what your benefits entail, your eligibility, co-pay and any deductibles that you may have. Mental Health benefits may differ from your medical benefits so it is essential that you have researched your mental health benefits prior to your visit. If you have not done this prior to your visit, and/or your treatment is not a payable benefit, you will be responsible for the full cash payment at the time of service. Further, if your insurance carrier determines that the services received are not medically necessary, you will be responsible for full payment of your accrued fees.
Re-Disclosure: I understand that once my health care provider discloses my health information to the recipient identified above, my health care provider cannot guarantee that the recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.