Authorization for Treatment/Release of Authorization/Assignment of Benefits Do you authorize medical/psychological/clinical therapy treatment. I also authorize the release of any information necessary to process my insurance claims. I authorize and request payment of medical benefits directly to Provider. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.*YesNoWho authorizes Treatment (Please list name below) If you are younger than 18 years, your guardian will need to authorize Treatment*Relationship to Patient *SelfParentLegal GuardianIdentified Health Care SurrogatePower of AttorneyThis site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.SUBMITThank you! Your Authorization Form was successfully sent.Return to Forms / PreviousNextPausePlayClose