Upload Your Files

1
Patient Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.Patient D.O.B.:
Date
Month
Day
Year
3
What are you uploading?* This field is required.Please tell us what document(s) you are uploading:
Photo Identification
Primary Insurance Card (front & back side)
Secondary Insurance Card (front & back side)
Medication List
Lab Results
New Patient Registration Form
Release of Information Form
Medical Records from Primary Care Provider (PCP)
Medical Records from other healthcare provider
Power of Attorney Document
Healthcare Surrogate Document
4
Select which insurance company you are updating/uploading? (if none, then select 'NONE')* This field is required.What Insurance Company are you uploading/updating?
AARP Supplemental plan
Aetna HMO
Aetna PPO
Aetna Medicare Advantage HMO
Aetna Medicare Advantage PPO
Bankers Life or Colonial Life
BCBS / Florida Blue HMO
BCBS / Florida Blue PPO
BCBS / Florida Blue
BCBS (BlueCross BlueShield) outside of Florida plan
BCBS Medicare Advantage HMO
BCBS Medicare Advantage PPO
Beacon Health
Cigna
Golden Rule
Humana
Humana Medicare Advantage HMO
Humana Medicare Advantage PPO
Magellan Health
Medicare (Traditional medicare)
Mutual of Omaha
Tricare EAST
Tricare For Life
UMR
United American Insurance
United Healthcare / United Behavioral Health / Optum Behavioral
United Healthcare Medicare Advantage AARP
United Healthcare Medicare Advantage
United Healthcare Dual Complete
NONE, not updating/uploading insurance info
5
What is the Effective Date of Insurance? and What is your insurance member ID number(s)?If you are uploading more than 1 insurance, then identify your member id numbers as "Ins1:" and "Ins2:" before each of your member id numbers.
6
What is the effective date of this insurance update?
Date
Month
Day
Year
7
Upload your files here* This field is required.If you have a mobile device or iPad with a camera, you can take a picture of your photo id and/or insurance card(s). Then upload the picture from your photo gallery -Or- if you already have these and other documents in your files, then upload them.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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Insurance Assignment and Self Pay Agreement

If you are uploading and providing updated or new insurance plan coverage, you agree to the folllowing terms:

I certify that I have insurance coverage with the primary insurance company, if applicable; and the secondary insurance payer, if applicable. I assign directly to "Cornerstone" Psychiatric Services, Inc. (including David Donahue, D.O., David Fawks, APRN, Nina Kirchgessner, APRN, Smitha Ajesh, APRN, Joan Flynn, LCSW and Nancy Stetter-Coblentz, LCSW or any staff of Cornerstone Psychiatric), all insurance payments, if any, otherwise payable to me for services rendered. I understand I am financially responsible for deductible, co-payments, co-insurance amounts, non-covered charges, and any and all balances not covered under a contractual agreement between "Cornerstone" and my insurance or other third party payer. I authorize the use of my signature for all insurance submissions. I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made on my behalf to "Cornerstone" for any services furnished to me by that provider.

If Self pay, I understand it is my responsibility to pay for services rendered at time of visit.

I understand and agree that "Cornerstone" may use my health care information to the insurance payer I am providing and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I understand that if an authorization is needed from my insurance plan, it is my responsiblity to obtain such authorizaton from my insurance plan and provide this to "Cornerstone".

All Document Uploads Agreement

I agree that the documents uploaded are being granted/released to Cornerstone Psychiatric Services, Inc. I give consent for Cornerstone Psychiatric Services and their Business Associates's to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). I agree to not hold "Cornerstone" liable for anything related to uploading documents provided on this service.

By signing this form, you are consenting to the above assignment and agreements. I may revoke my consent in writing to Attn: Privacy Officer - Cornerstone Psychiatric Serivces, except to the extent that the practice has already made disclosures in reliance upon my prior consent.
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Signature* This field is required.By signing this form, you are consenting to the above assignment and agreements. I may revoke my consent in writing to Attn: Privacy Officer - Cornerstone Psychiatric Serivces, except to the extent that the practice has already made disclosures in reliance upon my prior consent.
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