FORM

INSURANCE INFORMATION / FINANCIAL RESPONSIBILITY
(COPY OF INSURANCE)

Primary Insurance: MemberID#:

Medicare #: Medicaid #:

INSURANCE ASSIGNMENT AND AUTO PAYMENT AUTHORIZATION FOR PUBLICATION

I certify that I have an insurance account with the primary insurance company, if applicable; and the payment of the secondary insurance, if applicable, listed above. Medical Prestige Services Corp. (including but not limited to any provider/Clinician that provides service for the group) all insurance payments, if applicable, payable for the services rendered. I understand that I am financially responsible for a deductible, co-pays, coinsurance, missed appointment fees, uncovered charges and any other outstanding balance not covered by the contract between Medical Prestige Services Corp and my insurance, other third-party payments. I authorize the use of my signature for all insurance submissions. I would like this Medicare benefit payment, if applicable, and the Medigap benefits to be made in my name to Medical Prestige Services Corp for any service provided by this provider. If paying out of pocket, I understand that it is my responsibility to pay for the services rendered at the time of the visit.
I understand and agree that Medical Prestige Services Corp. may use my signature to bill their services for the purpose of paying for services rendered. I understand that it is necessary to obtain my authorization and it is my responsibility to obtain it and provide it.

Date:

Please Take Note

If you need any of the following forms, please inform the administrative staff. The medical provider (MD, APRN, LMHC, LIMHC) will not take time to discuss these issues during your personal visits.

• FMLA (Family and Medical Leave Act)
• Emotional Support Animal
• Social Security Disability Forms
• Immigration Form (N 648)
• Public School Forms
• Jury Service

Additionally, if you are prescribed any psychotropic medication, the medical provider will issue the prescription for 30 days only. NO refills will be given over the phone or fax. If the medication is controlled, multiple refills will not be provided. If you believe this may affect or be a problem in following your medication treatment plan, please speak directly with your provider or the office manager.

CONSENT FOR IN-PERSON / TELEMEDICINE TREATMENT

By signing below, I authorize Medical Prestige Services Corp. to perform any evaluation and treatment procedures that may be necessary for my care. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

Patient Name:

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I certify that I am the father or legal guardian of . I hereby authorize Medical Prestige Services Corp to conduct the evaluation and treatment procedures necessary for the mental health care of my child.

Minor's Name: Birth Date:

Name of the Father or Guardian: