I authorize Cynthia Z. Mealer, Ph.D., William F. Mealer, Ed.D., or their agents, to furnish my insurance carrier(s) information they may request concerning my own or my dependent's treatment. I assign to Mealer Psychological, PLLC or to Dr. Mealer all payments for services rendered myself or my dependents. I understand my rights under HIPPA and confidentiality. I understand that I am financially responsible for any amount not covered by insurance. All charges are due and payable at the time of service.
I have read and understood the practice policies of Mealer Psychological, PLLC and information regarding HIPPA rights and confidentiality. I have had the opportunity to ask any questions or address any concerns.
Why are you seeking therapy at this time?
This form allows Dr. Mealer to charge your credit card for copays so that you do not have to remember cash or a check at each appointment.
Your information will be kept separately from your clinical record in a secure and private location.
Balances may also be charged to a credit card if you prefer.
I authorize Dr. Mealer to keep my signature on file and to charge my account for balances of charges not paid by insurance for services provided including late cancellations and no show charges.
__ Recurring charges of $__________ (copay amount) for each appointment beginning on __________.
I understand that this form is valid for four (4) years unless I cancel the authorization through written notice to Dr. Mealer.