2. BILLING PAYER RELEASE.
A. I authorize CMMHC to release all Mental Health and/ or Substance Use Disorder (SUD) information electronically, on paper, or orally to my third-party payer(s) (e.g., Medical Assistance, county of financial responsibility, insurance company, designated care management organization, Prior Authorization, etc.)
B. I hereby authorize, from this day forward, any insurance company to whom I subscribe to pay directly to CMMHC for services rendered to me and/or my dependents.
C. I accept full responsibility for notifying CMMHC immediately of any changes in my insurance coverage while receiving care. If I provide insurance coverage information, I understand that my financial responsibility cannot be determined until my insurance company processes the claim. Failure to provide insurance coverage information will result in me being fully responsible for the bill.
D. I understand that if I cannot pay my balance in full, I am able to set up payment arrangements. I also understand that I may be eligible to apply for a reduced rate through Sliding Fee Scale (income limits may apply) Sliding Fee Application needs to be completed prior to the service and required documents/ verification of gross income is required within 30 days of application.