Holistic Mental Healthcare- Intake and New Patient Registration
Insurance Information
Financial Agreement
I, the undersigned, authorize the release of any information related to claims for benefits filed on behalf of myself and/or my dependents. I also acknowledge that by signing this document, I authorize my healthcare provider to submit claims for services rendered or to be rendered without requiring my signature on each claim for myself and/or my dependents. This authorization binds me to the claims as if I had personally signed each one. Additionally, I authorize the prescribing staff at Holistic to act as my representative for all pharmacy-related appeals.
I
hereby authorize
to pay and assign directly to Holistic any benefits payable to me for services described in the attached forms. I understand that I am responsible for all charges incurred, regardless of whether they are covered or deemed medically necessary by my insurance provider. Furthermore, I acknowledge that any insurance benefits received by Holistic on my behalf will be applied to my account based on the above assignment.