Lagasse & Yates, Psychology Corporation	Insurance Authorization

CA License: PSY12670

Susan Lagasse, Ph.D.	susanlagasse@sbcglobal.net

12625 High Bluff Drive Suite 206

San Diego, CA 92130

858-793-8768

Insurance Information:

Primary Insurance Name: _____________________________________________

Insurance Phone Number: ____________________________________________

Who is Insured: ____________________________ Date of Birth: ____________

Insured ID/Subscriber ID Number: ___________________________

Insured Group Number: ____________________________________

Is there a secondary insurance? __________________________________________

Assignment of Insurance Benefits/Signature Release:

I, the undersigned, certify that I (or my dependent) have insurance coverage as listed above and assign directly to Lagasse & Yates, Psychology Corp all insurance benefits, if any, otherwise payable to me for the services rendered.

I understand that I am financially responsible for all charges whether or not paid by insurance.

I hereby authorize Lagasse & Yates, Psychology Corp, or their representative, to release all information necessary by mail or electronically, to secure payment of benefits.

I understand that I may be charged for appointments not cancelled within 24 hours. I am responsible for co-pays, deductibles or other fees not covered by insurance. Insurance usually covers specific medically necessary services and I am responsible for payment of other professional services.

I authorize the use of this signature on all insurance submissions.

____________________________________________ __________________________________

Patient Signature (or Responsible Party) Date