I hereby authorize payment of medical benefits through my insurance policy to HRA Psychological Services. I have listed all health plans from which I may receive benefits. I hereby accept responsibility for payment for any services provided to me that are not covered by my insurance.
I agree to pay all copayments, coinsurance, and deductibles at the time services are rendered. I also accept responsibility for any missed appointment/late cancellation fees, NSF check fees, and a $10.00 charge per month on all overdue balances (past 60 days
I hereby authorize HRA Psychological Services to use and/or disclose my health information which specifically identifies me or that can reasonably be used to identify me to carry out my treatment, payment, and health care operations.
I understand that while this consent is voluntary, if I refuse to sign this consent, HRA Psychological Services can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions taken by HRA Psychological Services prior to receipt of my revocation.
I further give authorization to run my credit card if I choose to call and pay for services over the phone.
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