to Request Prior Authorization & Bill Insurance
I, the undersigned, hereby certify and attest that I have sought evaluation, treatment, or medical advice from the staff at the clinic named above. I therefore authorize the medical staff and personnel to release my or my minor child's medical information to the insurance company listed above for the purpose of determining and receiving benefits for medical bills.
I understand and acknowledge that the medical staff will submit my claim to the insurance company on my behalf. I further understand that I will be held responsible for any amount of my medical bills not covered by my insurance policy or claims, and that I will be responsible for paying all deductibles, fees, co-payments, and co-insurance payments required.
I understand that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided above. Non-compliance or defaulting on payments may result in denial of service and/or a legal claim against me for non-payment.
This notice applies to the following entities:
Freedom Healthcare, LLC dba Community Wellness Center, 3310 Eastern Avenue, Baltimore, MD 21224
Freedom Health Systems, Inc., 3310 Eastern Avenue, Baltimore, MD 21224
Community Wellness Outpatient Mental Health Center, LLC, 3310 Eastern Avenue, Baltimore, MD 21224
Community Wellness Psychiatric Rehabilitation Program, LLC, 3310 Eastern Avenue, Baltimore, MD 21224
HolBrock Estates Supportive Housing Programs, LLC, 3310 Eastern Avenue, Baltimore, MD 21224
Lighthouse Behavioral Health Center, LLC, 1119 E Monument Street, Baltimore, MD 21202
This notice is effective January 1, 2023.
Privacy Official contact information
The Privacy Official is designated as Jevon Patrick, LMSW. His email address is email@example.com. His phone number is 443-708-5056 EXT 1001.