Please complete this form first. By completing this form you must agree to all terms and conditions below. All items in bold are required to submit the form.

In consideration of the provision of services to the above named patient rendered by Penfield Psychiatry, I agree to be obligated to pay any remaining balance due not covered by my/patient’s insurance carrier(s).

Terms of completing this form:
By submitting this form, I authorize Penfield Psychiatry to release to parties responsible for payment of my/patient’s mental health service bill(s) such information as may be necessary for the completion of financial obligation. Additionally, I consent to my information being shared with the clinicians of Penfield Psychiatry for the purposes of evaluation. All such transactions will be undertaken under conditions of strict confidentiality. This form is submitted for the purpose of screening insurance information and evaluation. It does not constitute doctor-patient confidentiality or imply acceptance as a patient.

Please note: Due to the influx of new patient referrals, there may temporarily be slight delays in getting back to you. Thanks for your patience and understanding.