Authorization to Release Medical Information to Insurance Carrier

I understand that my express consent is required to release any health care information relating to assessment and treatment. I hereby, give my consent for A to Z Behavioral Services, LLC to release my child’s medical and other relevant information to our insurance carrier as required by my/our insurance carrier to process medical billings, process my claims and to establish service eligibility/authorizations throughout my child’s service.

For Clients Without Insurance:

• Clients without insurance coverage are expected to make monthly payments. An invoice will be issued at the beginning of the month following services, with payment due by the end of that month. A sliding scale may be available on a case-by-case basis for those facing financial difficulties.

For Clients with Insurance:

• Clients must provide valid insurance information at the onset of services and if there are any changes to the plan.
• It is the client’s responsibility to confirm that we are an in-network provider with their insurance company.
• If we are an in-network provider, we will complete and submit the necessary forms. Secondary insurance will also be billed when applicable.

In-Network Plans:

• Clients are responsible for paying any co-payment or designated portion of charges as specified by their plan at the time of the visit.
• Any medical services not covered by the insurance plan are the client’s responsibility, and full payment is required at the time of service. Clients should contact their insurance provider’s member services department (phone number listed on the insurance card) for coverage details.

HMO or Managed Care Plans:

• Clients must pay any required co-payment or cost share as outlined by their plan.
• It is the client’s responsibility to ensure that any necessary referrals for treatment are provided at the time of the visit. Failure to provide a required referral may result in rescheduling the appointment or financial responsibility for the visit.
• We reserve the right to charge fees for completing forms, letters (e.g., insurance documents or program applications), and copying medical records.
• Unpaid balances that are not settled in full or under a payment plan agreement may be transferred to an external collection agency.

Missed Appointments and Late Cancellations:

• A fee may be charged for missed appointments or cancellations made with less than 24 hours’ notice. Clients must notify the scheduling secretary or clinician to avoid this charge.