Behaven Kids

Patient Name: *

First Name Last Name

Patient DOB: *

Date

Authorization to File a Claim: I hereby authorize Behaven Kids to file a claim for services to my insurance plan, Medicaid, and/or any other government agency for reimbursement. I request that Behaven Kids furnish any and all information they may require from my record in order to process such a claim. *

Signature

Assignment of Benefits: I hereby authorize benefits from my insurance plan, Medicaid, and/or any other government or private plan to be paid directly to Behaven Kids, which will be credited to my account. I also understand that I am financially responsible for any amounts not covered by my insurance company including co-payments, co-insurance amount, deductible and any amount over the usual reasonable and customary guidelines. This includes services deemed non-covered or experimental by my insurance plan. *

Signature

Notice of Privacy Practices Receipt: Your electronic signature indicates that you have received a copy of and/or had the opportunity to request a copy of the Behaven Kids "Notice of Privacy Practices." *

Signature

Client Rights and Responsibilities: Your signature indicates you have received a copy of and/or had the opportunity to request a copy of the Behaven Kids "Clients Rights and Responsibilities." *

Signature

Patient Termination: Provider will have the right to terminate a patient relationship with a Covered Person who becomes abusive, noncompliant clinically or financially or, in the professional judgement of the Provider, is not following the professional guidelines for mental health services as directed by Provider. Provider may also terminate and/or initiate collection efforts, for non-payment of amounts rightfully due to the Provider. *

Signature

Interpreter Services: Your signature acknowledges that you will be responsible for the full amount set by the Interpreter for No-Show appointments, Amount will be waived if 24-hour notice is given. *

Signature

Date Signed: *

Date