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 the "I Accept" button, 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 GYV Inc. 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.