Authorization to Release Information: I authorize Dr. Saurabh Gupta to release any information necessary, acquired in the course of my treatment, to process insurance claims.
Authorization to Pay Beneﬁts Directly: Health insurance is a contract between you and an insurance company. As such, it is your responsibility to determine if the services provided by Dr. Saurabh Gupta are covered and to what extent they are covered. By initializing here, you understand that you will be responsible for all non-covered charges. You are authorizing your insurance company to pay Dr. Saurabh Gupta directly for medical services rendered, and you hereby assign all such policy beneﬁts to Focus Behavioral Health.
*Initial Notice of Privacy Practices: I acknowledge that Dr. Saurabh Gupta has adopted a notice of privacy practices. I also understand that I have an opportunity to view that notice.
Financial Policy: Unless covered by medical insurance, payment is due, in full, at the time services are rendered.
*Initial Here Medical Record Release: I hereby authorize any licensed physician, medical practitioner, therapist, or any other medically related facility, or other organization or person that has any records or knowledge of my health to give to Dr. Saurabh Gupta any such information, if so requested. I have read the office policy and agree to follow the terms and service. I am requesting a copy of the office policy to be printed for my own records.
*Initial Date: We Do Not Accept Workers Compensation or No Fault Claim
Please fill forms below as appropriate before your appointment