I hereby certify that I have sought evaluation, treatment, or medical advice from the staff at the clinic named above. Therefore, I authorize the medical staff and personnel to release my or my minor child’s medical information to the insurance company listed above for the purpose of
determining and receiving benefits for medical bills.

I understand that the medical staff will submit my claim to the insurance company on my behalf. I further acknowledge that I am responsible for any medical bills not covered by my insurance policy, including any deductibles, fees, co-payments, and co-insurance required.

I recognize that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided above. Failure to comply with payment obligations may result in denial of services and/or legal action for non-payment.

We participate in many insurance plans. If you are not insured by a company with which Thrive Mental Health Services does business, or if you do not have an up-to-date insurance card, payment in full is expected at each visit. When you provide Thrive Mental Health Services with current and complete information, Thrive Mental Health Services will bill your primary insurance. Please note that Thrive Mental Health verifies your benefits as a courtesy; this is not a guarantee of payment. We recommend that you confirm your coverage and network status wit your insurance company. If your insurance does not pay, you will be responsible for the charges. If you have any questions about your coverage, please do not hesitate to contact your insurance company.