Insurance Authorization Form

The Luminous Mind

Insurance Authorization Form
Client Full Name*

First NameLast Name
Client Date of Birth*
I (we) authorize Luminous Mind Inc (DBA The Luminous Mind) to disclose case records (diagnosis, case notes, psychological reports, testing results, or other requested material) to:
Select Primary Insurance Carrier*
write in name of insurance carrier if not listed in drop down menu above
Member ID Number*
Group Number*
Do you have secondary insurance?*

NoYes
Secondary Insurance Provider*
write in name of insurance carrier if not listed in drop down menu above
Secondary Insurance Member ID number*
Secondary Insurance Group number*
for the purpose of receiving payment directly to Luminous Mind Inc. I understand that access to this information will be limited to determining insurance benefits and will be accessible only to persons whose employment is to determine payments and/or insurance benefits. I understand that I may revoke this consent at any time by providing written notice. I have been informed what information will be given, its purpose, and who will receive it. I certify that I have read and agree to the conditions and have received a copy of this form.
Client or Guardian/Parent Signature*
DateTime
Should be Empty:

The Luminous Mind