Consent For Treatment/Financial Responsibility for Services

Consent for treatment: I authorize Alfredo Arellano's Psychiatric Clinic, its staff, and attending physicians to render to the patient all customary care, therapy, treatment, test and procedures considered advisable, including emergency treatment and transportation to another facility if necessary. Further consent is also given for any diagnostic procedures, medical treatment, x-ray treatment, urine toxicology tests, genetic testing, and other treatment ordered by Alfredo Arellano and/or attending physicians including but not limited to services provided by other Healthcare Professionals to the patient. In the event of a medical emergency, CPR will be performed and the patient will be transported to the nearest Emergency room for further medical treatment. I acknowledge that the patient is under the care of a psychiatric professional(s) and the Clinic is not liable for any act or omission in following the instructions of psychiatric professional(s). The undersigned further recognizes that the patient may be billed separately by their attending physicians and/or other healthcare professionals for their services provided.

Guarantee of payment: I guarantee the payment of the bill for services rendered by Alfredo Arellano Psychiatric Clinic. I agree whether signing as guarantor or as patient, that in consideration of the services to be rendered to the patient, to be hereby jointly and individually obligated to pay the account (s) of the Clinic in accordance with the regular rates and terms of the Clinic. I understand I am responsible for all health insurance co-payments and deductibles. Should the account be referred for collection by an attorney or collection agency, the undersigned agree(s) to pay all attorney’s fees and other reasonable collection costs and charges that are necessary for the collection of any amount (s) not paid when due. I give permission to run a credit report on the guarantor or insured party if payment arrangements are requested on any accounts with Alfredo Arellano's Psychiatric Clinic.

Assignment of insurance benefits: In consideration of medical services rendered or to be rendered by Alfredo Arellano's Psychiatric Clinic, to the extent permitted by law, I hereby (I) irrevocably assign, transfer and set over to Alfredo Arellano's Psychiatric Clinic (II) all of my rights, title and interest to medical reimbursement, including, but not limited to, (III) the right to designate a beneficiary, add dependent eligibility and (IV) to have an individual policy continued or issued in accordance with the terms and benefits under any insurance policy, subscription certificate or other health benefit indemnification agreement otherwise payable to me for those services rendered by Alfredo Arellano’s Psychiatric Clinic during the pendency of the claim for this admission. Such irrevocable assignment and transfer shall be for the recovery on said policy (ies) of insurance but shall not be construed to be an obligation of Alfredo Arellano's Clinic to pursue any such right of recovery. I hereby authorize the insurance company (ies) or third-party payer (s) to pay directly to Alfredo Arellano’s Clinic to pursue any such right recovery. I hereby authorize the insurance company (ies) or third-party payer (s) to pay directly to Alfredo Arellano's Clinic all benefits due for services rendered. Under the assignment, the Clinic shall have the right to appeal any denied or delayed claims on behalf of the insured or beneficiary.

Insufficient insurance coverage: I understand if my insurance or other third-party coverage rejects the claim or pays only part of the claim, then I will be responsible for payment of the balance due, as determined by Alfredo Arellano's Psychiatric Clinic or other Healthcare Professional.

Primary/ Secondary insurance coverage: I understand it is my responsibility to furnish Alfredo Arellano's Psychiatric Clinic with all of my insurance policies in order to authorize my care. I understand if I did not provide all insurance information at the time of treatment, I will be responsible for any amount not paid by either carrier, including but not limited to denied days due to no pre authorizations.

Insured employer: I authorize Alfredo Arellano's Psychiatric Clinic to release and to obtain information from the Insured and/or Insured's Employer of the policy, regarding employment, verification of insurance coverage, benefits or any other information necessary to process the insurance claim.

No show or cancelled appointments less than 24 hours: Alfredo H. Arellano PMHCNS-BC,PA strives to provide timely and individualized care to all patients. We kindly request that if you will be unable to make your appointment, to notify the clinic 24 hours prior to your appointment. Failure to do so will result in a $100 charge for your missed appointment. This is due prior to rescheduling any other future appointment(s).