Authorization & Release Personal Health Information Form

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
Client's Name*
First Last
Client's Date Of Birth*
MM slash DD slash YYYY
Client's Email*
Third Party Payer's Information
Payer’s Name or Organization's Name
First Last
Payer's Phone
Payer's Email*
Enter Email Confirm Email
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).
Name
This field is for validation purposes and should be left unchanged.

Third Party Authorization to Disclose and Release Billing Information Form

Client's Information

Third Party Payer's Information

Counseling You Can Trust...

Credentials

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Third Party Authorization to Disclose and Release Billing Information Form

Client's Information

Third Party Payer's Information

Counseling You Can Trust...

Credentials

Evidence-Based Therapy

Reviews

Trusted