Consent for Services

Guarantee of Account

I agree to pay Crestpoint Wellness (CPW) for all charges for services not covered by a third-party payer. I understand that I am responsible for complying with my insurance company's rules and regulations regarding pre-certification and pre-authorization requirements. I agree that if preu0002authorization of services is required, unauthorized visits will be my responsibility for payment. CPW will assist in keeping track of the sessions used.

Insurance Consent

I request that payment of authorized benefits be made directly to CPW, including the clinic's participating clinicians (such as mental health professionals [MHPs], interns, physicians, and psychiatric nurse practitioners [PNPs]), for any services provided. I authorize CPW to release medical or financial information to payers as needed for claims processing, fraud investigations, or quality of care reviews.

Consent for Release of Information

I consent to the release of information about my medical condition to any health care provider working for CPW involved in my treatment. I understand that other clinic staff involved in billing, medical records review, and other necessary duties may also see my medical records. I further understand that staff may contact me to seek my opinion about the helpfulness of services I received or problems I encountered.

Consent for Trainees

I am aware that I may be attended by staff in training under the supervision of a licensed provider.

Acknowledgement and Attestation

I hereby agree to the above and that a photographic copy of this authorization is as valid as the original. This authorization expires after one year from the signature date but may be revoked or limited in writing by me at any time, but such revocation will not apply to information already released. I may disagree with the use of my medical records for any purpose listed above by crossing through the paragraph and initialing in the margin. I further understand that if I refuse or revoke consent to release of information (ROI), this may change my providers’ ability to continue providing services.

Client