Please provide us with the legal name of the patient
Please select your gender, if this is not applicable to you. Please select other.
Please select the applicable marital status.
Please provide the name of an emergency contact for us to reach in relation to urgent messages regarding the patient's care.
Please designate if the patient is a minor (Under 18 years of age at time of submitting this application)
Please provide the contact information for the patients mother. Please include their name, address (including city, state, and zip code), phone number, and date of birth.
Please provide the contact information for the patients father. Please include their name, address (including city, state, and zip code), phone number, and date of birth.
Please provide the contact information for the patients legal guardian. Please include their name, address (including city, state, and zip code), phone number, and date of birth.
Please provide the name of name of the primary insurance carrier. (The person that is listed the policy owner, generally whomever is paying for the insurance policy)
A guarantor is a financial term describing an individual who promises to pay a borrower's debt in the event that the borrower defaults on their loan obligation. Guarantors pledge their own assets as collateral against the loans. If the person responsible is the patient, you may type "Same as patient"
Please provide the patients gender.
In the event you have additional comments or questions, or wish to provide additional information or instruction or requests. Please do so here.
I acknowledge that I have received a copy of the Meadowlark Psychiatric Services HIPAA brochure located here: www.MeadowlarkPsych.com/hippa
I hereby authorize Meadowlark Psychiatric Services to furnish the insured’s insurance company information, which said insurance company, may request concerning my present circumstances. I further authorized Meadowlark Psychiatric Services to release diagnostic information relative to my treatment, to a laboratory or hospital of my choice, for billing purposes only. I hereby assign Meadowlark Psychiatric Services all money to which I am entitled for expenses relating to the services performed from time to time, but not to exceed my indebtedness to Meadowlark Psychiatric Services. It is understood that any money received from the above named insurance company over and above my indebtedness will be refunded to me when my bill is paid in full. I understand that I am financially responsible to Meadowlark Psychiatric Services for charges not covered by this assignment. I further authorize photocopies to be made of this authorization and assignment for attachment to any insurance form and authorize the insurance company to accept the photocopy. The authorization shall continue and be in force and effect until revoked in writing by me.
By selecting I understand and Agree", you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Meadowlark or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Meadowlark. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement.