*This form is completely confidential*

    Marital Status:

    I authorize the release of medical information necessary to process any of my insurance claims and I authorize payment of medical benefits directly to Alan Behrman & Associates, PC for services rendered. I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance of my account for any professional services rendered as well as any additional collection agency fees should their assistance become necessary. I am aware that if I will be charged the insurance allowable rate, or standard fee if private pay, for any missed appointments which are not rescheduled or cancelled within 24 hours of the scheduled appointment time. I authorize Billing Connections, LLC (contracted billing service for Alan Behrman & Associates, PC) to file a claim for these services (and to refile as necessary to collect) with the patient’s insurance(s) and bill the patient for any amounts for which they are responsible. I further authorize Billing Connections LLC to sign said claim(s) or any refiled claim on my behalf. The undersigned agrees, whether he/she signs as a parent, spouse, guarantor, guardian, or patient that in consideration of the services to be rendered to the patient, he/she hereby individually obligates himself/herself to pay the account. Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney’s fee and collection expenses.

    Insurance Information