Consent for Billing Medicare, Medicaid and Commercial Insurances
Please sign so we may have your MEDICARE AUTHORIZATION on file:
I authorize any holder of medical or other information about me to release to the Social Security Administration and Healthcare Financing Administration or its intermediaries or carrier any information needed for this or related Medicare Claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.
All Others Insurances and Co-insurances:
I request that payment of benefits be made on my behalf to Counseling Resource Services, Inc. and it’s rendering providers for any services furnished to me. I authorize the release of medical information to my insurance carrier if it is needed to determine benefits payable.
I hereby authorize CRS and/or it’s rendering provider to apply for benefits on my behalf for covered services rendered. I certify that the information I have reported with regard to my insurance coverage is correct, I further authorize the release of any necessary information, including medical information for this or any related claim, to my insurance carrier, (or in the case of Medicare part B benefits to the social security administration and healthcare financing administration).
I hereby authorize payment of all medical insurance benefits which are payable to me under the terms of my insurance policy to be paid directly to CRS and/or the rendering provider for services rendered. I further authorize the release of any information needed for processing of my insurance claims. A copy of this authorization may be used in the place of the original.
Financial Arrangements
It is important that you understand the following:
- Counseling Resource Services, Inc. and it’s rendering provider will accept assignment on all Medicare and other insurance claims.
- Accepting Assignment does not mean we will not bill you for amounts that are deemed to be patient responsibility such as deductibles, co-insurance, co-pays and any non-covered services. If we are participating with your insurance carrier or the network your insurance carrier utilizes, we have a negotiated contract with the carrier, and agree to accept their fee schedule and they will mail the payments directly to us. The balance after our negotiated rate is your responsibility. Depending on the plan, it may be a co-insurance amount, a co-pay amount or a deductible or a combination of thereof.
- Depending on your insurance policy, medical/mental health services may require a pre-authorization. It is your responsibility to obtain the appropriate authorization if it is required for your visit. The Mental Health Professional/CRS will help you in your request for an authorization from your primary care physician or PCP.
- There may be times when your insurance carrier requests information from you as the patient that we can- not provide. It is extremely important that you provide this information to your carrier, as they may deny the claims for payment. Therefore, the balance becomes patient responsibility.
I understand and agree that I am financially responsible for all charges not paid by my insurance company.
I understand that in certain circumstances Medicare or other insurances may decide that appropriate medical services are not medically reasonable or necessary under the Medicare law. I agree to be personally responsible for payment of these charges.
The undersigned hereby obligates him/her to pay the account for the medical/mental health services rendered. If this account is referred to a collection agency, the undersigned agrees to pay collection expenses.