INSURANCE ASSIGNMENT
I hereby authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim. I hereby authorize and request my insurance company to pay directly to Cathal P. Grant, MD, PA, any amount due on claims for services rendered to me or my dependent. This assignment shall remain in effect until revoked by me in writing. A photocopy of the assignment is to be considered as valid as the original.
I further agree that I am responsible for any deductible, copay, or other balance not covered by my insurance carrier. I understand that I am responsible for advising the office of changes in my insurance coverage and will be responsible for any amounts not covered due to failure of notification of insurance changes.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
CLIENT RIGHTS AND RESPONSIBILITIES
This statement is prepared to give you information regarding the services provided by the office of Cathal P. Grant, MD, PA. This includes client rights and responsibilities. By signing at the bottom of this statement, you are acknowledging that you have received a copy of the Office Guidelines and Policies and are aware of your rights and responsibilities as a recipient of services.
The office of Cathal P. Grant, MD, PA, will not publish, communicate, or otherwise disclose information in any records without your signed consent below or on a release of information form except in any case in which there appears to be a clear and imminent danger to yourself or another individual or if such records are required to be released for court proceedings. Employees of Cathal P. Grant, MD, PA, are also required by professional ethics and the laws of the State of Texas to report any potential or actual suspicion of abuse or neglect of a minor child or the elderly. By signing at the bottom of this statement, you acknowledge that you have received a copy of the Notice of Privacy Policies, which details how information may be used and disclosed as permitted under federal and state law.
The providers have a limited number of hours available each week. When a client cancels an appointment without sufficient notice, this not only prevents the patient from his/her scheduled appointment but may also disallow other clients from utilizing this time. Therefore, if you must cancel an appointment, you will be charged a fee if 24-hour notice is not given.
I authorize Cathal P. Grant, MD, PA, and/or employees of Cathal P. Grant, MD, PA, to exchange information regarding my mental health care, substance abuse treatment, or other medical or clinical information with:
I understand that this consent shall remain in effect throughout my treatment unless revoked in writing by me. I understand that when the information is disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected. I understand this consent can be revoked at any time except to the extent that disclosure in good faith has already occurred in reliance to this consent.
I have read and understand the information presented to me. I agree to honor the terms of this agreement. I understand that payment is due at the time of service by cash, money order, Visa, MasterCard or Discover. I, the undersigned patient (parent/guardian), do hereby consent to and authorize medical care and treatment by Cathal P. Grant, MD, PA, and/or employees of Cathal P. Grant, MD, PA.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
