Release of Information for Insurance Billing-Sharing is Healing
I authorize Sharing is Healing and all business partners to release billing information which may include client name, date and type of services, diagnoses codes, substance abuse information and/or treatment plans to my insurance company/ies for the purpose of: collecting insurance benefits or for authorization of additional sessions for:
Date of Birth
By checking each statement, I endorse the information.
I understand that I have the right to inspect the information released through this authorization and such an inspection will occur in a meeting with Michelle Roling.
I understand that I may revoke this authorization by providing a written revocation.
I also understand any information released prior to the revocation may be used for the purpose(s) listed above.
This release shall be valid for one year following our last appointment, unless otherwise restricted.
Although your BCBS or Midland’s Choice Health insurance MAY cover all your fees, ultimately it is your responsibility to cover all your costs. Some plans require preauthorization before your first visit. It is YOUR responsibility to obtain this authorization. Mental Health benefits may differ from your medical benefits so it is essential that you have researched your mental health benefits prior to your visit. If you have not done this prior to your visit, and/or your treatment is not a payable benefit, you will be responsible for the full cash payment at the time of service. Further, if your insurance carrier determines that the services received are not medically necessary, you will be responsible for full payment of your accrued fees.
Upload a PDF of your insurance card/s front & back
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