3rd Party Authorization to Disclose and Release Billing Information

A 3rd 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 3rd party payer it is necessary for MCO be able to release and discuss billing information to that party. Please specify the identity and contact information for the 3rd party payer and sign to authorize release and discussion of billing information with that party.

For those clients who are having their sessions paid for by a third party, such as a church or friend of the family, permission must be given for MCO to release and discuss billing information. The following release authorizes MCO to release and discuss that billing information to the 3rd party person designated. No other information about the counseling will be provided to this 3rd party.

Client's Information
Client's Name*
First Last
Client's Date Of Birth*
MM slash DD slash YYYY
Client's Email*
3rd 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).

Client's Information

3rd Party Payer's Information