Patient Insurance Update Form

Patient Information First Name: Last Name: Date of Birth: Best Contact Number: Email Address: What state are you being seen in?

Check this box if you elect to be Self-Pay

Insurance Information Patient's Insurance Provider Other Insurance Patient's relationship to policy holder Policy Holder's Name Policy Holder's Date of Birth Policy/Member ID Number Policy Group Number RXBIN Number (if applicable) Who is the provider you are scheduled with?

Does the Patient have a referral or authorization?

Referral / Authorization Number: Scan and attach the Referral / Authorization

Scan and attach front and back of insurance card Scan and attach front of ID card corresponding to name on insurance card

Is there a Secondary Insurance?

Secondary Insurance Information Insurance Provider Other Insurance Patient's relationship to policy holder Policy Holder's Name Policy Holder's Date of Birth Policy/Member ID Number Policy Group Number RXBIN Number (if applicable)

Scan and attach front and back of insurance card Scan and attach front of ID card corresponding to name on insurance card

Surprise Billing Protection Acknowledgement and Consent Form

This Acknowledgement and Consent Form describes your protections against unexpected bills. It contains important information about your rights and protections. It also asks if you would like to give up those protections and pay more for out-of-network care.

IMPORTANT: You are not required to sign this form. If you do not sign, this clinician or facility might not treat you. You can choose to get care from a clinician or facility in your health plan's network, which may cost you less.

If you would like assistance with this document, ask your clinician. Take a picture and keep and/or copy the form for your records.

You are getting this notice because this clinician or facility is not in your health plan's network and is considered out-of-network. This means the clinician or facility does not have an agreement with your plan to provide services. Getting care from this clinician or facility could cost you more.

If you sign this form, be aware that you may pay more because:

You are giving up your legal protections from higher bills.
You may owe the full costs billed for the items and services you get.
Your health plan might not count any of the amount you pay towards your deductible and out-of- pocket limit. Contact your health plan for more information.

Before deciding whether to sign this form, you can contact your health plan to find an in-network clinician or facility. If there is not one, you can also ask your health plan if they can work out an agreement with this clinician or facility (or another one) to lower your costs. By signing, I understand that I am giving up my federal consumer protections and may have to pay more for out-of-network care. With my signature, I am agreeing to get the items or services from (select all that apply):

By signing, I understand that I am giving up my federal consumer protections and may have to pay more for out-of-network care.

With my signature, I am agreeing to get the items or services from (select all that apply): Mindpath Health Clinician Name:
Mindpath Health Practice Name:

With my signature, I acknowledge that I am consenting of my own free will and I am not being coerced or pressured. I also acknowledge that:

I am giving up some consumer billing protections under federal law.
I may have to pay the full charges for these items and services or have to pay additional out-of-network cost-sharing under my health plan.
I was given written notice that explained my clinician or facility is not in my health plan's network, described the estimated cost of each service, and what I may owe if I agree to be treated by this clinician or facility.
I got the notice either on paper or electronically, consistent with my choice.
I fully and completely understand that some or all of the amounts I pay might not count towards my health plan's deductible or out-of-pocket limit.
I can send this agreement by notifying my clinician or facility in writing before getting services.

Name of Consent Signer Enter the name of the individual who will be signing the consent.

Indicate Signer Patient Parent Conservator Health Care Surrogate Power of Attorney for Health Care Executor / Administrator

I understand that by typing my name as the Consent Signer and clicking “Submit”, I am electronically signing this document.

Submit

Patient Insurance Update Form

Patient Self-Pay Agreement

Surprise Billing Protection Acknowledgement and Consent Form

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