Financial Policies and Benefit Assignment- Read and Sign
I authorize Georgia Psychiatry & Sleep to furnish information as necessary to my insurance carrier regarding my illness and treatment, and I assign to Georgia Psychiatry & Sleep all insurance payments for medical services rendered. I understand that I am responsible for providing all necessary information to the office for submitting charges to the insurance company for payment. If I fail to provide this information, I accept the financial responsibility of payment for services rendered. This office has a cancellation policy that requires 24-hour advance notification. I understand that if I cancel with less than 24 hour notice, a charge will be made for the time reserved. This change is not covered by insurance and is not payable from any insurance company.