Behavioral Health Providers General Insured / Guarantor Form

Behavioral Health Providers General Insured / Guarantor Form

Please fill out as much of the following Behavioral Health Providers General Insured / Guarantor Form as you can.

Behavioral Health Providers will only use the information you provide on the General Insured / Guarantor Form for billing purposes with your healthcare insurance provider.

We may use or disclose your healthcare information to a physician or other healthcare provider providing treatment to you.

Insured / Guarantor acknowledgement of responsibility for payment of services

Thank you for choosing Behavioral Health Providers.

Unfortunately, paperwork is a necessity in modern health care. Please fill out all of the following necessary fields on this form.

When satisfied with your responses on this form hit the Submit button below to return this form to Behavioral Health Providers.

Insured / Guarantor Contact Information

Name *

First

Middle

Last

Relation to patient *

Birth date *

Gender you identify as *

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Employer Contact Information

Employer *

Employer Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Insured / Guarantor Prefered Contact Method

We will make every effort to only contact you by your prefered method listed below.

Home Phone

Home Phone Preference

• Ok to call / message
• Do not call / message

Mobile Phone

Mobile Phone Preference

• Ok to call / message
• Do not call / message

Work Phone

Work Phone Preference

• Ok to call / message
• Do not call / message

Email *

Signature of Insured / Guarantor *

Clear Signature

I understand that I am responsible for the payment for services rendered to me by Behavioral Health Providers, P.C. regardless of whether I am reimbursed for these services by my insurance company, and if any inaccuracy in information on this form may result in nonpayment by any insurance company. I have obtained preauthorization from any insurance company if it is a requirement to receive benefits.

Today's date *

By hitting submit to return this form to Behavioral Health Providers, P.C. I acknowledge, affirm, and certify the following.
I have read this Behavioral Health Providers Insured / Guarantor Acknowledgement of Responsibility Form carefully.
I have filled in this form completely and to the best of my ability.

Submit

Behavioral Health Providers Additional Forms

• GENERAL PATIENT INFORMATION
• INFORMED CONSENT FOR TELEVISITS FORM
• FINANCIAL & TREATMENT POLICY
• PRIMARY CARE PHYSICIAN NOTIFICATION OF CLINICAL SERVICES AND CONSENT FOR THE RELEASE OF INFORMATION
• TREATMENT OF A MINOR CONSENT FORM