Consent for Use of Third-Party Billing Services

Consent for Use of Third-Party Billing Services

Email: elevatedprimarycare316@gmail.com Phone: (206)395-4748
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Date

MonthDayYear
Date
I acknowledge and consent that Elevated Image & Primary Care utilizes OceanStack, a third-party billing service, to manage billing and insurance-related processes. I understand that OceanStack may communicate with me periodically regarding billing and payment matters on behalf of ICare Psychiatry.

By signing below, I authorize ICare Psychiatry to share relevant information with OceanStack solely for the purposes of billing and payment management. I also acknowledge that all communications and data handling will be in compliance with applicable privacy and confidentiality laws, including HIPAA.
Parent/Guardian Signature for Minor and Date

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Client Signature and Date

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Please include the name and phone number of any person you wish for me to contact in case of an emergency or crisis.Name of Emergency Contact:
Emergency Contact Phone Numeber:

Area CodePhone Number
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