Use the Above Form To Authorize Payment For
- Deductibles: Your fixed annual payment before your insurance plan starts to pay.
- Medication: Payments for prescribed medications not covered by insurance.
- Out-of-Pocket Expenses: Any medical costs not covered by insurance.
- Co-pay: Your share of the costs of a covered healthcare service, calculated as a preset fee.
- Additional Individual Counseling: Private sessions that are not covered by your insurance plan.
- Room & Board: Charges for your stay if not fully covered by insurance.
- Emergency Healthcare: Immediate medical care needs.
- Incidentals (Money on Books): For small purchases while in treatment.
