* Required Information

Existing Patient: Revise all information that has changed since your last visit

Responsible Party (If patient is minor):

Please fill in the following information:

Assignment of Insurance Benefits

I, the undersigned, hereby authorize the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my provider to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and even claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim.

I, hereby authorize (Name of Insured) (Name of Insurance Company) to pay and hereby assign directly to all benefits, if any, otherwise payable to me for his/her services as described on the attached forms. I understand I am financially responsible for charges incurred. I further acknowledge that any insurance benefits, when received by and paid to will be credited to my account, in accordance with the above said assignment.

Medicare Authorization
IF YOU ARE COVERED BY MEDICARE, PLEASE SIGN AND DATE BELOW

I request payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Vishnu Maya, DNP, ARNP, WHCNP-C, FNP-C /Maya Healthcare Clinic/ Maya Behavioral Health for any services furnished to me by MHCC/MBH. I authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits payable for related services. I understand my signature requests that payment be made and authorize release of medical information necessary to pay the claim. If +other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the health care provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services, Co-Insurance and the deductible are based upon the charge determination of the Medicare carrier.

Financial Policy

I have read and understand the financial policies of Maya Healthcare Clinic/ Maya Behavioral Health. By my signature I agree to the terms outlined in the financial policies.

Consent for Treatment

I (or my legal guardian/parent) authorize Maya Healthcare Clinic/ Maya Behavioral Health to provide medical and mental healthcare reasonable by today’s standards including appropriate laboratory testings.

Insurance Authorization and Assignment

I hereby authorize Maya Healthcare Clinic/ Maya Behavioral Health to furnish information to insurance carriers concerning my medical and mental health illness and treatment and hereby assign to the Maya Healthcare Clinic/ Maya Behavioral Health all payments for medical and mental healthcare service rendered to myself or my minor child(ren). I understand that I am responsible for providing insurance information or I will be considered private pay. I understand that I am responsible for any amount not covered by my insurance. I hereby authorize the Social Services Department to contact and provide appropriate information to outside community resources as deemed necessary
Guarantor Statement:
I (guarantor) assume all financial responsibility for the payment of all charges for services rendered to the patient.

Please present your insurance card and picture ID to the receptionist with this completed form

NOT ALL INSURANCES ACCEPTED

HIPAA

THIS NOTICE DESCRIBES AN OVERVIEW OF HOW MEDICAL INFORMATION ABOUT YOU IS TO BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

How we may use and disclose your health information: We use health information about you for treatment, to get paid for treatment, for administrative purposes and to evaluate the quality of care that you receive. For example your health information may be shared with other providers to whom you are referred. Information may be shared by paper, mail, fax, electronic mail or other methods. We may disclose your health information without your authorization for several reasons but beyond those situation we will ask for your written authorization before using or disclosing your health information. If you sign an authorization to disclose information, you can later revoke it to stop any further uses and disclosures.

Your Right: In most cases you have the right to look at or get a copy of your health information that we use to make decision about you. If you request copies, we may charge you a cost based fee. You also have the right to request a list of certain types of disclosures of your information that we have made. If you believe your health information is incorrect or information is missing, you have the right to request that we correct the existing information or add the missing information.

Our Legal duty: We are required by law to protect the privacy of your health information, and we are willing to do everything possible to protect your information.

Privacy Complaints: If you are concerned that we have violated your privacy rights, or if you disagree with a decision we made about your access to your health information, you may contact the person listed below. You may also send a written compliant to the US Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.If you have any questions or complaints, please contact:

Risk Management/Quality Management at 817 201 1627

Acknowledgement of receipt of Notice of Privacy Practices