For insurance clients: INSURANCE AUTHORIZATION FORM

Client’s First Name: ______Middle Initial: ______Last : ______

Date of Birth: ___/___/____ Age: ______Sex: ( ) Female ( )Male

Address: ______City: ______State: ______Zip: ______

Phone: ______

Social Security (if needed) #: _____/_____/_____

Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Separated ( ) Widow Other:

Responsible Party: ______Relationship: ______

______

I authorize the release of medical information necessary to process any of my insurance claims and I authorize payment of medical benefits directly to Deborah Mauldin, LICSW for services rendered. I understand and agree that I am ultimately responsible for the balance of my account for any professional services rendered. I authorize Deborah Mauldin, LICSW to file a claim for these services with the patient’s insurance and to bill the patient for any for any amounts for which they are responsible.

Print Name: ______Relationship to patient: ( ) Self ( ) Parent ( ) Spouse ( ) Guardian

Signature: ______Date: ______

Insurance Information

Policy Holder (if different from Client): ______Relationship: ______

Date of Birth: ____/ _____/ _____ Employer: ______

Insurance Company Name: ______Phone #:______

Policy ID Number: ______Group Number: ______

As a service to you, I will bill your insurance company. Be aware that insurance benefits have become increasingly more complex. In some cases session visit limits, deductibles, or maximum allowable may vary, thereby altering or altogether preventing claims from paying in accordance with the benefits the provider has on file. Therefore, it is the responsibility of the client to keep in contact with their insurance provider concerning their mental health benefits (co-pays, deductibles, number of sessions available).

TO BE COMPLETED BY BILLING OFFICE

Date: ______Spoke with: ______Circle one: In Network Out of Network

Policy Effective: ______Co pay Per Visit: ______Coinsurance Per Visit: ______

Deductible Amount: $______Deductible Met: $______Max Visits/Max Payable Per Year: ______

Out of Pocket Max Per Year: ______Exclusions to policy: ______

Claims Address: ______City: ______St:______Zip:______

Authorization #: ______Sessions Approved: ______Authorization Date: ______thru ____

Notes: