Supervision and Incident Billing Authorization Form for Stacey Carabin, APRN-CNP, PMHNP-BC; LISW
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電子郵件 *
Patient First and Last Name *
Patient Date Of Birth *
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Parent or Guardian Name if patient is under the age of 18
By signing below, I acknowledge that my treatment provider, Stacey Carabin, PMHNP is not yet credentialed to bill my insurance at this time. *
I understand that all therapy services rendered by Stacey Carabin, PMHNP will be reviewed by and billed to my insurance company under Johanna Wilson, MD until which time she is credentialed under my insurance company. *
I further authorize all services to be billed to my insurance by Johanna Wilson, MD, and understand that EOBs I receive from my insurance company will list Johanna Wilson for these services. (This enables me to see Stacey Carabin and have my services billed as in-network under Johanna Wilson, MD Medical Director) *
I understand that I have the right to refuse these services to be billed in this way, but my insurance company will process all charges as out-of-network and my copays or deductibles may be higher or my insurance may not cover the services provided by an out-of-network provider. *
CHOOSE ONE OF THE FOLLOWING - I agree OR I do not agree to the above incident billing of all services provided by Stacey Carabin, PMHNP. *
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By typing your name below, you certify that you have read and agree to all the items above, and agree to be held by the consequences of these acknowledgments. (Please type the full legal name of the person completing this form. By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.) *
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