BJC Behavioral Health Authorization for Treatment and Financial Responsibility
Consent to Treat
I request treatment of BJC Behavioral Health. I consent to routine diagnostic evaluation, case management, therapy, and medication management deemed medically necessary. I understand that BJC Behavioral Health makes no guarantees to me as to the results of treatment or evaluation.
Utilization Review
In the event the client herein is covered by an insurance agreement, Missouri Department of Mental Health funds, health maintenance organization and/or preferred provider organization, my treatment may be subject to utilization review concerning my care at BJC Behavioral Health.
Financial Responsibility
In Consideration of services rendered and to be rendered to the client herein, the undersigned Responsible Party agrees to pay BJC Behavioral Health for services rendered to the above-named client. A Client eligible for services under the Department of Mental Health criteria is not responsible for more than the amount determined by the Department of Mental Health Standard Means Test. Members of health maintenance organizations and/or preferred provider organizations are generally required to comply with certain policies and procedures requiring use of participating providers and compliance with plan requirements for primary referral, emergency admission, pre-certification and utilization review. These are conditions to payment of benefits by companies, health maintenance organization and/or preferred provider organizations. By signing this form, which includes a statement about financial responsibility, I, as the client and/or guarantor, acknowledge and agree that I am responsible for payment of billed charges rendered in any case in which payments denied by the companies, health maintenance organizations and/or preferred provider organizations because of a failure to comply with such coverage requirements or for any other reason.
Assignment of Outpatient Behavioral Health Benefits
I hereby assign payment of any insurance benefits, including Medicare and Medicaid, otherwise payable to me, to be paid directly to BJC Behavioral Health for treatment charges. I also authorize and direct any holder of medical and other information about me, as it pertains to my health care, to release all needed information to determine benefits payable. I request that payment of authorized benefits be made on my behalf.
Medicare Assignment Certification
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize and direct the release of medical or other information to the Medicare Program or its intermediaries or carriers concerning this or a related claimed by BJC Behavioral Health. I request that payment of authorized benefits be made on my behalf.
Acknowledgement of Receipt of Notice of Privacy Practices
I have received, or I have been provided the opportunity to receive, a copy of the “Notice of Privacy Practices” that explains when, where, and why my confidential health information may be used or shared. I acknowledge that BJC Behavioral Health, the physicians, the nurses, and other BJC Behavioral Health staff may use and share my confidential health information with others in order to treat me, in order to arrange for payment of my bill and for issues that concern BJC Behavioral Health’s operations and responsibilities.
Confirmation