By engaging in services with BMHC:

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I authorize the release of information as may be required by my insurance company, their reimbursing agency, or as may be otherwise necessary for payment of claims resulting from my mental health treatment.

 

I understand information will be disclosed for processing claims for treatment I have received, quality review and continuity of care purposes. This may include information contained in my records that concerns medical illness, mental

illness or substance abuse, and/or domestic violence.

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I authorize payment directly to Baker Mental Health Consulting, LLC. of benefit otherwise payable to me.

 

 I understand that I am financially responsible for any deductible, co-insurance, non-covered charges, or charges resulting from my failure to follow my insurers’ referral guidelines.

  

I understand that I may revoke this release at any time, but I must notify Baker Mental Health Consulting, LLC. of my revocation in writing.