Authorization and Office Policies

* Required Field
Date of scheduled appointment*
MM slash DD slash YYYY
Practitioner Name
Patient Name*
First Last
Patient Email*
AUTHORIZATION – RESPONSIBILITY AGREEMENT
Consent*
I authorize the practitioner named above to release medical information related to my medical condition and treatment to any Insurance Company for filing insurance claim. I authorize any Insurance Company to pay proceeds of any benefits due me directly to the practitioner named above. Regardless of any insurance benefits, I understand that I am fully responsible for the payment of all fees for services rendered.
Signature*
Date*
MM slash DD slash YYYY
OFFICE POLICIES
I have read my practitioner's office policies posted on their website profile
Signature of Patient/Responsible Party*
Date*
MM slash DD slash YYYY
Consent*
I agree to Office Policies
Coverage: I am a separate and independent practitioner, who shares space in the building along with other mental health professionals. Other doctors and/or therapists will cover from time to time while I am on vacation or out of the office. Any covering provider or I can be reached at my office number 513-961-8830 (24 hour answering service).*
I agree

AUTHORIZATION – RESPONSIBILITY AGREEMENT