Patient Information

Insurance Information of Patient Covered by the Following Legal and Financial

Responsible Party

Primary Insurance

Secondary Insurance

Parent/Guardian Completing Form

Attach Insurance Card Copy

Consent and Release

I hereby consent to treatment by, and authorize insurance benefits to be paid directly to Autism Spectrum Mandate Services. I agree that I am responsible to pay for services not covered by my insurance company, co-payments and deductibles, and for any expense associated with the collection of a debt owed to them.

I also consent to the release of pertinent medical insurance information to my insurance carrier(s) for the purpose of processing health care claims.