Non-Custodial Parent Consent and Assignment of Benefits

Patient's Name:
Patients Date of Birth:
Today's Date:

Introduction: Psychiatric Specialists of Texas (PSOT) is a professional association that provides
psychiatric services primarily to children and adolescents. Each patient’s treatment will be
individualized to his or her needs.
The professionals who are members of the team working with PSOT and who may serve the patient are
physician assistants and nurse practitioners. A summary of the qualifications of those individuals will
be provided upon request. Any questions or concerns regarding professional services provided under
PSOT may be discussed with any member of our professional team.

Fees: All fees are billed to the appropriate insurance provider shortly after services are
provided. Fees cover evaluations, assessments, individual therapy, and family therapy as needed.
Your insurance provider will send a statement, an Explanation of Benefits, of all of our services.
Confidentiality: Information about the resident is kept confidential in accordance with our privacy
policy and requirements by the Health Insurance Portability and Accountability Act (HIPAA).
Medical, legal, billing and ethical requirements specify certain conditions when it is necessary to
share information about the patient with other professionals. The patient’s insurance provider
sometimes requests clinical information to support payment. Insurance companies are responsible for
keeping this information confidential just as we are.

Consent to Photograph: I hereby authorize the office of PSOT to photograph the patient for
identification purposes and for quality assurance purposes.

Assignment of Benefits: My right to payment for all procedures and services including major medical
benefits are hereby assigned to PSOT. This assignment covers any and all benefits under Medicare,
other government sponsored programs, private insurance, and any other health plans. In the event my
insurance carrier does not accept assignment of benefits or, if payment is made directly to my
representative or me, I will endorse such payments to PSOT. I understand that I am responsible for
any charge not reimbursed by Medicare or other insurance coverage that is in effect. I authorize
Medicare or any other insurance carrier to release my personal data and any information regarding
my coverage to PSOT. I also authorize agents of any hospital, nursing home, long-term care facility
or previous psychiatrists or psychologists to furnish PSOT copies of any records of my medical
history, services, and/or treatments. I also authorize the release of any medical information
and/or reports related to my treatment to any federal, state, or accreditation agency, or any
physician or insurance carrier as needed. I also agree to a review of my records for purposes of
audits and quality assurance reviews within PSOT

I have read this document and understand the information contained in it. I understand that this
informed consent and assignment of benefits will remain in effect unless revoked by me in writing.

Non-custodial parent notified and/or signed:

Electronic Signature Disclosure and Consent:
By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor. When I sign the document, I will receive a copy of this document via email.
Signer's Name
Signer's Date of Birth: