•   INTEGRAL HEALTH ASSOCIATES

  • Insurance Update Form

  • Please have your insurance card (or digital copy of the card) at hand to complete the form. Thank you. 

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you currently have active medical insurance?

  • Your provider is currently out-of-network with your insurance.  Please be aware that our services will be subjected to cash rates.  If you provide us your insurance information, we can submit claims upon receiving full payment for services rendered. Any out-of-network benefits will be sent directly to you from your insurance company.  Please follow up with your insurance company to make sure claims have been received and processed.  Thank you. 

  • Your provider may be out-of-network with your insurance and our services may be subjected to cash rates.  Please call our office or your insurance company to verify.  Thank you. 

  • While your provider's status is "non-participating" Medicare may reimburse for a portion of services rendered.  Please be aware that our services will be subjected to cash rates.  If you provide us your insurance information, we can submit claims upon receiving full payment. Any benefits will be sent directly to you from Medicare. If you are unable to pay the full cash rate for services, please contact our office immediately to cancel your appointment.  Thank you. 

  • Your provider is currently out-of-network with Medicare Advantage plans.  Please be aware that our services will be subjected to cash rates.  If you are unable to pay the full cash rate for services, please contact our office immediately to cancel your appointment.  Thank you. 

  • IMPORTANT NOTICE for Yale Graduate or Professional Students

    If you are a Yale graduate or professional student with Magellan insurance, please contact Magellan before your scheduled appointment to obtain a prior authorization specifically for your session with {myCurrent}. This must be completed prior to your appointment to prevent your claim from being denied. Magellan will provide you with an authorization number - please keep this number for your records.  

  • Date of Birth of Primary Person Insured
     - -
    2 digit month, 2 digit day, 4 digit year
  • Plan Effective Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have secondary insurance?

  • Your provider is currently out-of-network with your insurance.  Please be aware that our services will be subjected to cash rates.  If you provide us your insurance information, we can submit claims upon receiving full payment for services rendered. Any out-of-network benefits will be sent directly to you from your insurance company.  Please follow up with your insurance company to make sure claims have been received and processed.  Thank you. 

  • Your provider may be out-of-network with your insurance and our services may be subjected to cash rates.  Please call our office or your insurance company to verify.  Thank you. 

  • Your provider is currently out-of-network with Medicare Advantage plans.  Please be aware that our services will be subjected to cash rates.  If you are unable to pay the full cash rate for services, please contact our office immediately to cancel your appointment.  Thank you. 

  • IMPORTANT NOTICE for Yale Graduate or Professional Students

    If you are a Yale graduate or professional student with Magellan insurance, please contact Magellan before your scheduled appointment to obtain a prior authorization specifically for your session with {myCurrent}. This must be completed prior to your appointment to prevent your claim from being denied. Magellan will provide you with an authorization number - please keep this number for your records

  • Date of Birth of Primary Person Insured
     - -
    2 digit month, 2 digit day, 4 digit year
  • Plan Effective Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Patient Authorization


  • 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.

  • RELEASE OF INFORMATION

    I authorize IHA to obtain, use, and disclose medical, behavioral health, billing, and related healthcare information as necessary for treatment, payment, healthcare operations, insurance processing, referrals, care coordination, and prescription management, as permitted by applicable law. I understand that I may revoke this authorization in writing except to the extent action has already been taken in reliance upon it.

    ASSIGNMENT OF INSURANCE BENEFITS & FINANCIAL RESPONSIBILITY

    I authorize IHA to release any and all necessary medical information to my insurance carrier for the purpose of processing claims. When applicable, I authorize IHA to act as my agent in dealing with my insurance carrier to obtain payment and authorize payment of insurance benefits directly to IHA. I accept full responsibility for all charges not paid by insurance, including co-payments, deductibles, coinsurance, missed appointment and late cancellation fees, and other patient-responsible balances. This includes full balances if insurance coverage is denied or terminated. Insurance verification is not a guarantee of payment. If I receive payment from my insurance company for services provided to me by IHA, I agree to submit the payment to IHA. If my account is not paid, I will pay all costs incurred as a result of IHA's collection efforts, including, without limitation, attorney's fees and court costs.

    As a courtesy, IHA may assist me in processing insurance claims; however, I understand IHA accepts no responsibility for any processing procedures, acts, omissions, or neglect. I understand IHA does not guarantee coverage, eligibility, or reimbursement by the insurance company. I understand I am responsible for understanding my insurance benefits and keeping IHA informed of current insurance information. I understand IHA does not submit insurance claims directly for all out of network or self pay services. If I elect to self-pay for services, I understand that IHA will not bill insurance directly, and that I may request a detailed receipt (superbill) to submit directly to my insurance carrier for possible out of network reimbursement, if applicable. I understand that reimbursement is determined solely by the insurance company and is not guaranteed.

    If my bill is not paid in full in a timely manner, I understand IHA reserves the right not to provide future services to me.  

    Signature of Patient, Parent, or Legal Guardian (click on signature line):

    *   *   *   

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Magellan Health - Members' Rights and Responsibilities Statement


    Members have the right to:

    • Be treated with dignity and respect.
    • Be treated fairly, regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.
    • Have their treatment and other member information kept confidential. Only where permitted by law may records be released without the member's permission. 
    • Easily access care in a timely fashion.
    • Know about their treatment choices. This is regardless of cost or coverage by their benefit plan.
    • Share in developing their plan of care.
    • Receive information in a language they can understand, and free of charge.
    • Receive a clear explanation of their condition and treatment options.
    • Receive information about Magellan, its providers, programs, services and role in the treatment process.
    • Receive information about clinical guidelines used in providing and managing their care.
    • Ask their provider about their work history and training.
    • Give input on the Members' Rights and Responsibilities policy.
    • Know about advocacy and community groups and prevention services.
    • If asked, Magellan will act on the member's behalf as an advocate.*
    • Freely file a complaint or appeal and to learn how to do so.
    • Know of their rights and responsibilities in the treatment process.
    • Request certain preferences in a provider.
    • Have provider decisions about their care made on the basis of treatment needs.
    • Receive information about Magellan's staff qualifications and any organization Magellan has contracted with to provide services.*
    • Decline participation or withdraw from programs and services.*
    • Know which staff members are responsible for managing their services and from whom to request a change in services.*


    Members have the responsibility to:

    • Treat those giving them care with dignity and respect.
    • Give providers and Magellan information that they need. This is so providers can deliver quality care and Magellan can deliver appropriate services.
    • Ask questions about their care. This is to help them understand their care.
    • Follow the treatment plan. The plan of care is to be agreed upon by the member and provider.
    • Follow the agreed upon medication plan.
    • Tell their provider and primary care physician about medication changes, including medications given to them by others.
    • Keep their appointments. Members should call their provider(s) as soon they know they need to cancel visits.
    • Let their provider know when the treatment plan is not working for them.
    • Let their provider know about problems with paying fees.
    • Report abuse and fraud.
    • Openly report concerns about the quality of care they receive.
    • Let Magellan and their provider know if they decide to withdraw from the program.*

  • * This standard is required for our Condition Care Management (CCM) products.

    My signature below shows that I have been informed of my rights and responsibilities, and that I understand this information.

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

    The signature below shows that I have explained this statement to the patient. I have offered the member a copy of this form. 

    ________________________________
    Provider Signature

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please provide a copy of your driver's license or other photo ID and a copy of both sides of your insurance card by uploading them using the button below.

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  • If you're unable to submit them now, please submit them using the online Document Submission Form on our website or via fax. Our preferred fax number is (203) 777-6776 and our alternate fax number is (203) 909-6374. 

     

     

    When you are finished responding to the above questions, please click the submit button below.   

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