Patient Demographic

COMMUNICATION AUTHORIZATION

I authorize the following person/people to communicate with StressCare Behavioral Health, Inc. regarding canceling or scheduling appointments and/or billing and insurance issues. I understand that this does not authorize these individuals to have information about my psychotherapy.

ASSIGNMENT OF BENEFITS FOR TREATMENT

I hereby authorize treatment and authorize the provider of medical services to release information for these services to my insurance carrier for payment. I further authorize that payment of benefits be made to the provider on my behalf, or to myself. I understand that I am financially responsible for all charges not covered by my insurance. I understand that failure to adhere to this agreement may jeopardize my treatment.