Financial Contract

"*" indicates required fields

CASE#*

DATE*

ORIGINAL

REVISED

Client Name*

Social Security Number

Head of Household

Social Security Number

Street

Street Address City State / Province / Region ZIP / Postal Code

Phone

Medicaid Number

Medicare Number

Primary Insurance Co.

Policy Number

Group No.

Secondary Insurance Co.

Policy Number

Group No.

ACCEPTANCE OF FINANCIAL RESPONSIBILITY

ASSIGNMENT OF INSURANCE BENEFITS

RELEASE OF INFORMATION

I hereby authorize the release of information to insurance companies, Medicaid, Medicare, and other parties responsible for payment; such information will include date and nature of service (including treatment for alcohol and drug abuse) charge for services delivered, diagnosis, clinician, and anticipated length of treatment. This information will be released for the purpose of filing for insurance benefits and other financial coverage.

Client Signature*