Medicaid Benefits Waiver

I understand that Statesboro Psychiatric Associates (SPA) does not participate in the Georgia Medicaid Program, which includes Medicaid, Amerigroup and Wellcare/Magellan of Georgia. I understand that although I do have mental health benefits through this program, and may obtain mental health services through an in-network provider who does accept this coverage, I choose to receive care at Statesboro Psychiatric Associates. Neither the copayments associated with my primary insurance nor additional fees for services rendered may be submitted to Medicaid and are my sole responsibility.

Patient Name

Name of Responsible Party (if not the patient)

Signature of Responsible Party/Patient

Date

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