LABELS & GRAPHICS VERTICAL SPACING BOTTOM OF TOP ITEM TO THE TOP OF THE BOTTOM ITEM
LABELS & GRAPHICS VERTICAL SPACING BOTTOM OF TOP ITEM TO THE TOP OF THE BOTTOM ITEM
Patient's Relationship to the Insured/Subscriber:
Insurance Carrier Information:
INSURANCE CARRIER ADDRESS
NAME OF INSURANCE CARRIER
LAST NAME
FIRST NAME
Name of Insured/Subscriber (As shown on the insurance card):
Insured/Subscriber I.D.# & Group #:
INSURED/SUBSCRIBER I.D.#
GROUP #
GRANT AUTHORIZATION
"My full legal name will act as my signature."
"I authorize the release of any medical or other information necessary to process my claim. I authorize payment of medical benefits to the physician or supplier for services described on my claim."
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*SPECIAL NOTE:
The charges for services provided may or may not be covered by your insurance carrier. You are advised to check with your insurance carrier as to the extent of coverage and psychological services.
Click this box for a checkmark to indicate "Yes I grant authorization"
*
REQUIRED: Please enter your first and last name to complete the assessment.
insurance
authorization
FIRST NAME
LAST NAME
*
*
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