Tricare Insurance Benefit Waiver

I recognize that Statesboro Psychiatric Associates does not accept assignment for or file claims with Tricare. In order to obtain treatment at SPA, I agree to waive my Tricare insurance benefit, and not file claims on my own behalf for office visits. I also accept the responsibility of full payment for my visits at the time of service.

If claims are filed by the patient and Tricare makes payment to Statesboro Psychiatric Associates, it will be returned to the insurance company. If payment is made to the patient, we DO NOT accept the Tricare fee schedule. The billed amount, not the allowed amount is the patient responsibility.

I understand that there are other psychiatrists in Georgia who accept Tricare and I may chose to receive treatment at another practice. Medical records will be forwarded with patient's written request.

Patient Name

Name of Responsible Party (if not the patient)

Signature of Responsible Party/Patient

Date

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