Authorization of Treatment

Authorization for Treatment/Release of Authorization/Assignment of Benefits

Patient Name*

First NameLast Name

I, Name* (patient or guardian of patient) authorize medical/psychological/clinical therapy treatment. I also authorize the release of any information necessary to process my insurance claims. I authorize and request payment of medical benefits directly to Provider. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.

Signature (Of Patient or Patient Representative) *

Date/Time*

Date

If signed by Other than the Patient: PRINT Patient Representative's Name

First NameLast Name

What is your relationship with the Patient and/or the authority (e.g.,Self, Parent, Legal Guardian, Identified Health Care Surrogate, Power of Attorney, etc *

Please upload Proof of Identity (Drivers License / Guardians Drivers License)*