TO RELEASE INFORMATION: I hereby authorize Desert Canyon Treatment
Center to release any information required for payment or to process
claims in the course of my treatment which may include HIV, Communicable
disease or drug abuse information. This assignment will refer to copies
and fax tranmittals and will remain in effect until revoked by me in
AUTHORIZATION TO PAY: I hereby authorize payment directly to
Desert Canyon Treatment Center for benefits otherwise payable to me
for services. I understand that I am ultimately responsible for all
services rendered to me regardless of insurance or other legal issues.
This assignment will remain in effect until revoked by me in writing.
INSURANCE AGREEMENT: Insurance companies do not guarantee payment
even after benefits have been quoted. In addition, they usually dont
disclose their allowables until after a claim has been submitted, which
is after you have completed your program. Finally, insurance companies
usually quote benefits as a percentage of what they consider a reasonable
and customary expense, an amount that differs considerably from one
company to the next. While we consider the cost of our program to be
very reasonable and competitive, we cannot guarantee total coverage
by your insurance company. Desert Canyon makes full effort to collect
insurance payment. However, in all situations, you are responsible
for full and total payment of the fees of the program.
By clicking I AGREE below, you are authorizing Desert Canyon as
described above and you are agreeing to the Insurance Agreement. If
you are using insurance for payment, your application will not be
processed without this agreement.