MH Services & Financial Agreement - Client Self-Service
A. PERMISSION FOR TREATMENT
I agree to permit employees and interns of Minnesota CarePartner to provide services to me. I understand that Minnesota CarePartner can make no guarantees about the outcome of my treatment, but that I can expect to receive services that are ethical and professional. I understand that Minnesota CarePartner agrees to comply with all privacy laws and respects my right to confidentiality. As a client, I agree to attempt to be honest and to disclose information to assist the MNCP staff in providing appropriate services.
Under the above conditions, I provide my consent to receive services from Minnesota CarePartner:
B. FINANCIAL AGREEMENT
I authorize Minnesota CarePartner to release to Minnesota Health Care Programs, its agents, or any insurance company, any information needed to process claims, determine benefits or the benefits payable for related services.
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. I hereby authorize Minnesota CarePartner to release all information necessary to secure the payment.
2. Insurance claims will be handled as follows:
I do not want Minnesota CarePartner. to file claims to my insurance company, and I will pay fees in full upon receipt of an invoice for services. I do not have insurance to cover services performed by Minnesota CarePartner and will pay fees in full upon receipt of an invoice for, or prior to, services as required. Minnesota CarePartner will file claims to the insurance I have indicated, and I will pay any balance not paid by insurance. If my insurance is discontinued, I will pay fees in full upon receipt of invoice for services.
If my insurance company sends me payment for services performed by Minnesota CarePartner and I have not yet paid my balance in full, I will make payment of at least the amount received from insurance within five working days.
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Document Name: MH Services & Financial Agreement - Client Self-Service
Agree & Sign