Third Party Authorization to Disclose and Release Billing Information Form

Pursuant To The Health Insurance Portability And Accountability Act Of 1996 (Hipaa). A third party payer is defined as someone other than the client who has agreed to pay for counseling services. If you are a client with a third party payer, it is necessary for MCO be able to release and discuss billing information such as session dates to that party. Please specify the identity and contact information for the person or organization paying for your counseling and sign to authorize the release and discussion of billing information with that party. No other information about the counseling will be provided to this third party.

  • Client's Information

  • MM slash DD slash YYYY
  • Third Party Payer's Information

  • Please note: If you’re authorizing a Referring Organization for use of a scholarship, MCO may have a designated contact for scholarship approvals that we will contact for approval. Listing the Organization Name authorizes MCO to contact our designated contact(s).