Insurance information (Please present insurance card for photocopy)
In order to submit a claim for payment, for services covered under your policy, we require authorization to release medical information to our billing company. I authorize the release of any medical information necessary to process my medical service claims. I permit a copy of this authorization to be used in place of the original. I hereby authorized Lansing Institute of Behavioral Medicine and its associated billing company to file for benefits on my behalf for any and all medical services rendered. Insurance claim and patient payments shall be made directly payable to Lansing Institute of Behavioral Medicine. If I have Medicare insurance, I authorize Lansing Institute of Behavioral Medicine and its associated billing company to release to the Social Security and Care Financing Administration or its intermediaries or carriers any information needed for a related Medicare claim. I certify that I am financially responsible for all services not paid by insurance. I hereby authorize Lansing Institute of Behavioral Medicine to provide the following treatment; Psychiatric Evaluation, Psychotherapy and Medication Evaluation/Treatment. These authorizations are valid indefinitely until revoked in writing by myself or by Lansing Institute of Behavioral Medicine.