BALZ05 Acknowledgement Form

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Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

CONSENT TO TREAT

I hereby consent and authorize Balanced Mental Health of AZ to furnish me or the above registered patient with necessary medical care. This care may include ancillary care including but not limited to laboratory testing, radiologic examinations and other diagnostic procedures as deemed necessary by the professional staff at Balanced Mental Health of AZ. I understand that the services recommended to, or provided to me are in my, or the registered patient’s, best interest. I understand that I have and reserve the right to revoke this consent at any time and for any reason during my treatment at Balanced Mental Health of AZ. I consent to be contacted by mail, email, and telephone regarding matters related to my treatment or patient account Balanced Mental Health of AZ and entities formally associated with Balanced Mental Health of AZ. Initials *

ASSIGNMENT OF BENEFITS

I authorize payment directly to Balanced Mental Health of AZ for all medical benefits otherwise payable to me under terms of my insurance. I understand that I am financially responsible for all co-payments, co insurance, deductibles, and non- covered services. Overpayments on my account at Balanced Mental Health of AZ account may be applied to my patient balance. Initials *

FINANCIAL AGREEMENT

By making an appointment with Balanced Mental Health of AZ and electronically signing this form, you agree to the following:

Place a credit card on file during your intake process to remit co-pay and/or payments
Place your health insurance card on file through this intake process
Agree to remit co-pays per your insurance plan agreement
Agree to pay for your appointment after your insurance remittance is received

Insurance authorization and deductible: You agree to be solely responsible for checking if your plan is in network with Balanced Mental Health of AZ and associated fees/tiers that may impact your coverage. You agree to be solely responsible for knowing the status of your plan deductible and any out-of pocket expenses due before your insurance covers your medical expenses. If you don't agree to any of the above, you agree to cancel your appointment immediately. Initials *

PATIENT RIGHTS AND RESPONSIBILITIES

I will treat the staff and clients of Balanced Mental Health of AZ with dignity and respect. Verbally expressed profanities and vulgarities toward any staff or other patients of Balanced Mental Health of AZ will not be tolerated and could be grounds for service termination. I will make every attempt to arrive at my appointment on time. I will make every attempt to cancel appointments at least 2 hours before or it will be considered a No Show. Repeat of no shows could result in you losing privileges to schedule future appointments. I have been given the opportunity to ask any questions I have about my care through Balanced Mental Health of AZ. I can request a copy of all authorization documents such as Notice of Privacy Practices (HIPAA), Patient responsibilities, and Balanced Mental Health of AZ Responsibilities and Duties. I understand that I am expected to make every attempt to pay any payment due, copayment, or coinsurance amount at the time of service, but understand that an inability to pay will never prevent me from being treated at Balanced Mental Health of AZ.Initials *

Digital SignatureAuthorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient/Legal Guardian Signature *