Authorization to Provide Services
I authorize the Northwestern Mental Health Center, Inc. and its employees to provide me, my dependent or other person for whom I am authorized to sign with eligible services. The services may be provided individually, in groups and/or may include the support network of the individual receiving care.
Authorization for Payment & Release of Liability
I authorize Northwestern Mental Health Center, Inc. to disclose all information and records necessary to bill for the services I receive from the agency. The Northwestern Mental Health Center, Inc. is authorized to disclose this information to any insurer, payer, or benefits provider responsible for payment for my and/or my dependent’s health care services, and/or for whose benefits I may be eligible, including government payer’s such as Medicare, Medical Assistance and Workers’ Compensation. Additionally, I authorize the exchange of information with my and/or my dependent’s Primary Care Provider when required by the insurance company. I release the Northwestern Mental Health Center, Inc. from any liability associated with the exchange of information for billing purposes.
Statement of Financial Responsibility
I acknowledge that I am responsible for all charges for services provided to me, to my spouse, to my minor child(ren) or to any other individual for whom I serve as the guarantor, including charges not paid by my insurance plan. This also applies if I am covered by Medicare or any other third party payers. I understand the Northwestern Mental Health Center, Inc. reserves the right to pursue delinquent accounts through a collection agency and/or by other legal means, in which case(s) necessary client information shall be released.
I understand that if I do not authorize services, authorize the release of information for payment purposes and accept financial responsibility for services, the Northwestern Mental Health Center, Inc. may choose not to initiate services.
ATTENTION: This is a legal document. Please read carefully.
By signing, you agree that you understand and accept the terms in this form.
If the client is 18 years of age or older, the client must sign and date the form.
If the client is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form.
If the client is 17 years of age or younger, the client’s parent or legal guardian must sign and date the form, unless an exception exists under state or federal law.