Intake Forms


Insurance Authorization and Assignment

    I authorize the release of any medical information necessary to process any insurance claims and I authorize payment of medical benefits directly to Brill Counseling, for myself and/or dependents. I understand that I am responsible for any deductibles, co-insurances, or amounts for services not covered by the insurance carrier, including full session charges for missed appointments and those canceled less than 24 hours in advance.

    I also authorize Brill Counseling, to release any medical/mental health information that may be necessary for either medical care or in processing applications for financial benefit. I request that payment of authorized benefits be made on my behalf. A photocopy of these assignments shall be as valid as the original. I am aware and do consent and authorize, to disclose information pertaining to my identity, diagnoses, and treatment to the Utilization Manager and/ or any authorized Utilization Review/Managed Care Company or subcontractor employed by my insurance company. This information needs to be disclosed for the purpose of obtaining health insurance payments for charges incurred by the client as a result of treatment by Brill Counseling.

    I am aware that my records are protected under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (45 CFR, Parts 160 and 164), Federal regulation 42 CFR, Part 2 (Confidentiality of Alcohol and Drug Abuse Treatment), and the General Laws of the State of Wisconsin and cannot be disclosed without my written consent except as otherwise specifically provided for by law. I understand that, by law, I need not consent to the release of this information; however, I choose to do so willingly and voluntarily for the purpose specified above.

    Signature