INSURANCE INFORMATION
Secondary/Additional Insurance
Policy Holder____________________________________________________Relationship to patient_______________
Last First MI
Address___________________________________________________City/State/Zip____________________________________
Social Security Number_______________________________________Birthdate___________________________
Insurance Co___________________________________Ins. ID#____________________________Group#_____________
Ins. Co. Address_________________________________City/State/Zip________________________________________
Employer__________________________________________Work Phone____________________________________
BY SIGNING BELOW I CONSENT TO TREATMENT AND ACKNOWLEDGE THAT I HAVE RECEIVED A COPY
OF THE UNIVERSITY PSYCHIATRIC PRACTICE. INC.’S “NOTICE OF PRIVACY PRACTICES”
_____________________________________ ____________________
Signature Date
______________________________________
Print Name
PLEASE READ AND SIGN STATEMENT BELOW TO AUTHORIZE PAYMENT OF BENEFITS.
I AGREE TO THE ASSIGNMENTS AND FINANCIAL RESPONSIBILITIES INDICATED
BELOW:______________________________________________________________ __________________
Signature Date
_________________________________________________________
Print Name
It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your
insurance company.
IN ORDER TO CONTROL COST OF BILLINGS, WE REQUEST THAT OUR CHARGES FOR OFFICE
VISITS BE PAID AT THE CONCLUSION OF EACH VISIT. YOU MAY ALSO CHARGE YOUR VISIT TO
VISA, MASTERCARD, OR AMERICAN EXPRESS.
If this account is assigned to an attorney for collection and/or legal action, you will be responsible for associated
attorney fees and collection costs.
I authorize the release of any information to determine liability for payment and to obtain reimbursement on
any claim.
I request that any payment of authorized benefits be made on my behalf. I assign the benefits payable to which I
am entitled including Medicare, private insurance and other health plans to University Psychiatric Practice
Plan, Inc.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be
considered as valid as an original. I understand that I am financially responsible for all charges whether or not
paid by said insurance.
rev. 4/7/2003
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