Financial Policy/Insurance Assignment and Release

I certify that I (and/or my dependant(s)) have insurance coverage with the above carrier and assign directly to Dr. Alan Levy all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named provider may use my health care information and may disclose such information to the above named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one year form the date signed below.  

I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim, to the above-named insurance carrier(s).  I permit a copy of this authorization to be used in place of the original.  This authorization may be revoked in writing either by me or the above-named carrier at any time.  I certify that I represent only myself or individual(s) for whom I am guardian and am not here on behalf of a third party.  I authorize treatment by any or all providers and professional staff affiliated with Dr. Alan Levy