Psychiatric Services Assignment of Benefits Agreement

Psychiatric Services and Insurance Payment Authorization

Patient Information

Name: _________________________ Date of Birth: _____________ Insurance ID: ___________________ SSN: _____________________

Assignment of Benefits Authorization

I, the undersigned, certify that I (or my dependent) have insurance coverage with _______________________ (Insurance Provider) and assign directly to Dr. _______________________ all insurance benefits, if any, otherwise payable to me for services rendered.

Terms and Conditions

1. I understand that I am financially responsible for all charges whether or not paid by insurance.
2. I hereby authorize the doctor to release all information necessary to secure payment of benefits.
3. I authorize the use of this signature on all insurance submissions.

Financial Responsibility Agreement

• I acknowledge that any co-payments, deductibles, or non-covered services are due at the time of service
• I understand that my insurance policy is a contract between myself and my insurance company
• I accept responsibility for any charges that are denied or not covered by my insurance

Authorization for Release of Information

I authorize the release of any medical or other information necessary to process insurance claims. This includes:

• Diagnostic information
• Treatment plans
• Progress notes (when required)
• Medication management records

Signature Section

Patient/Guardian Signature: _________________________ Date: ____________

Printed Name: ___________________________

Provider Signature: _________________________ Date: ____________

Witness: _________________________________ Date: ____________