Authorization to Bill Insurance

Authorization to Bill Insurance
Client Name:
DOB:
Insurance Name:
Insurance Group#:
(if applicable)
Insurance Policy#:
I hereby give my consent for Aspire Care to bill my/my child’s insurance company for the services rendered to my child by Aspire Care. In addition, I agree to pay the company any deductible or uncovered charge in accordance with my healthcare plan.
Parent/Guardian Name
Date:

MonthDayYear
Date
Parent/Guardian Signature:

Clear
Authorization to Release Medical Information to Insurance Company
I understand that my express consent is required to release healthcare information relating to assessment and treatment. I, hereby give my consent to release medical and other relevant information to our insurance company as required by my insurance

company to process medical claims.
Parent/Guardian Name:
Date:

MonthDayYear
Date
Parent/Guardian Signature:

Clear
Should be Empty: