MH Services & Financial Agreement - Staff Requested


 

Minnesota CarePartner Mental Health Services Agreement

 

 

 

 Person signing forms is the:

 

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. 

  1. I agree to attend scheduled appointments or notify service providers if I need to reschedule an appointment. 
  2. I agree to participate in required treatment planning. 

Under the above conditions, I provide my consent to receive services from Minnesota CarePartner

 

 

 

B. FINANCIAL AGREEMENT

  1. I authorize Minnesota CarePartner to correspond with my insurance company as I have indicated, and with any insurance company with which I will be covered in the future to which I will ask Minnesota CarePartner to submit claims. I understand that it is my responsibility to know the benefits and limits of my insurance. I request payment of authorized insurance benefits be made to Minnesota CarePartner for any services furnished to me by any provider employed or contracted by this agency.  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:                                                                                                                                         
  3. 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.
  4. This form also authorizes the release of any medical information necessary to process this claim. I understand that I am financially responsible for charges not covered by this authorization. 
  5. I hereby request and authorize direct payment of benefits specified under my policy or any policy paying benefits to: Minnesota CarePartner 

 

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Signature Certificate
Document name: MH Services & Financial Agreement - Staff Requested
lock iconUnique Document ID: 9cfdd0c22f5ece269f47607b5c79f72b7a645396
Timestamp Audit
August 6, 2020 10:36 am CSTMH Services & Financial Agreement - Staff Requested Uploaded by MInnesota CarePartner - referrals@mncarepartner.com IP 75.72.214.61
August 6, 2020 10:38 am CSTClient info - info@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 10:38 am CSTClient Referrals - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 10:55 am CSTClient info - info@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 10:55 am CSTClient Referrals - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:17 am CSTClient info - info@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:17 am CSTClient Referrals - referrals@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:24 am CST Document owner rootsforms@mncarepartner.com has handed over this document to referrals@mncarepartner.com 2020-08-06 11:24:00 - 174.53.135.153
August 6, 2020 11:24 am CSTClient info - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
August 6, 2020 11:24 am CSTClient Referrals - referrals@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153