•   INTEGRAL HEALTH ASSOCIATES

  • Patient Authorization Form

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  • AGREEMENT TO RECEIVE TREATMENT

    I, {name}, agree and consent to participate in behavioral health care services offered and provided by Integral Health Associates.

    Signature of patient (Click on signature line):
    *   

    ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

    I, {name}, acknowledge that I have read the Notice of Privacy Practices of Integral Health Associates. Click here to view.

    Signature of patient (Click on signature line):
    *   

  • FINANCIAL RESPONSIBILITY

    I, {name}, hereby agree to pay all charges for services provided by Integral Health Associates for treatment. I agree to be personally responsible for such charges, including any fees associated for late cancellations, missed appointments, and late payments, including interest charges. Furthermore, I agree that if my account defaults because of my failure to pay the balance due, I will be financially responsible for the cost of payment collection, including collections agency and/or attorney fees and court costs permitted by law.   

    Signature of patient (Click on signature line):
    *   

  • RELEASE OF INFORMATION FOR INSURANCE PROCESSING
    (Please sign if you are using or plan to use insurance, otherwise leave blank.)

    I, {name}, hereby authorize Integral Health Associates to release medical information about me to my insurance company or managed care company for the purpose of documenting medical necessity and appropriateness of treatment, and for processing insurance claims.

    Signature of patient (Click on signature line):
          

  • AUTHORIZATION OF PAYMENT OF MEDICAL BENEFITS
    (Please sign if you are using or plan to use insurance, otherwise leave blank.)

    I, {name}, hereby authorize my insurance company or managed care company to pay my health insurance benefits directly to Integral Health Associates for any treatment provided.

    Signature of patient (Click on signature line):
         

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  • The patient, {name}, is under the age of 18 or is unable to consent to treatment. I,   *   * , attest that I have legal custody of this individual and/or am legally authorized to initiate and consent to treatment on behalf of this individual.

    AGREEMENT TO RECEIVE TREATMENT

    I agree and consent for {name} to participate in behavioral health care services offered and provided by Integral Health Associates.

    Signature of parent or legal guardian (Click on signature line):

    *   

    ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

    I acknowledge for {name} that I have been shown or given a copy of the Notice of Privacy Practices of Integral Health Associates. Click here to view.

    Signature of parent or legal guardian (Click on signature line):

    *     

  • FINANCIAL RESPONSIBILITY

    I hereby agree to pay all charges for services provided by Integral Health Associates for treatment. I agree to be personally responsible for such charges, including any fees associated for late cancellations, missed appointments, and late payments, including interest charges. Furthermore, I agree that if my account defaults because of my failure to pay the balance due, I will be financially responsible for the cost of payment collection, including collections agency and/or attorney fees and court costs permitted by law.   

    Signature of parent or legal guardian (Click on signature line):

    *   

  • RELEASE OF INFORMATION FOR INSURANCE PROCESSING
    (Please sign if you are using or plan to use insurance, otherwise leave blank.)

    I hereby authorize Integral Health Associates to release medical information for {name} to the appropriate insurance company or managed care company for the purpose of documenting medical necessity and appropriateness of treatment, and for processing insurance claims.

    Signature of parent or legal guardian (Click on signature line):  

        

  • AUTHORIZATION OF PAYMENT OF MEDICAL BENEFITS
    (Please sign if you are using or plan to use insurance, otherwise leave blank.)

    I hereby authorize the insurance company or managed care company to pay health insurance benefits for {name} directly to Integral Health Associates for any treatment provided.

    Signature of parent or legal guardian (Click on signature line):

       

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