I  hereby authorize Proactive Psychiatry to verify my insurance benefits and to release any necessary information to my insurance provider for the purpose of determining my coverage and payment responsibility for healthcare services I receive.

​

I understand that this information may include, but is not limited to, my demographic information, diagnosis codes, treatment codes, dates of service, and charges.

​

I understand that the information being shared is confidential and will only be used for the purpose of verifying my insurance benefits and determining payment responsibility for the healthcare services I receive.

​

This waiver will remain in effect until revoked by me in writing.

​

I understand that this is not a guarantee of services or insurance reimbursements.