Statement Delivery Form

Statement Delivery Election Form

North Star Behavioral Health
Insurance and Payment:
Because we are not contracted with any insurance plans, it is the patient’s responsibility to verify whether their insurance will provide reimbursement. Payment is due at the time of service and a credit card may be kept on file for automatic payment. We currently accept checks, Visa, and Mastercard. After appointments, we will provide you with paid statements that you can submit to your insurance company if you wish to. Please know that each statement includes service codes and diagnostic codes that are necessary for insurance to process claims. Choose your preferred option as below, and enter your e-mail address for statement e-delivery:
How would you like to receive statements?*

I would like to receive statements via regular email. I understand these messages are encrypted using HIPAA-compliant email encryption (Paubox), and they do not require a login or portal access. Please send statements to the following email address:I prefer to receive statements via the Valant patient portal and I understand that this is an encrypted method of communicationI do not wish to receive any statements at this time. I understand that I can request statements as needed which can be mailed to me at the address on file.
Enter the preferred email address for statement delivery:
Patient Name:*
Date of Birth:*

MonthDayYear
Date
By signing below, I acknowledge that I have read, understood, and agree to statement delivery:
Patient Name:*

First NameLast Name
Patient Signature:*

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Date*

MonthDayYear
Date
Should be Empty:

Statement Delivery Election Form