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Private Pay Patient Advocate Authorization Form

, I 
("Payer") authorize Preferred Case Management ("PCM"),located at 139 W. Lake Lansing Road, Suite 100, E. Lansing, MI 48823, to charge a $1,000 deposit on the following credit card to commence Patient Advocate services on behalf of   ("Client") :
* Card Type:
* Payer's Name:
* Card #:
* Payer's Address:
* Expiration Date:
* Phone Number:

Payer authorizes the $1,000 deposit to be applied to my final invoice when the Client's case is closed. Any unused portion will be refunded to the Payer. The Payer agrees that PCM may keep the Payer's credit card on file and the Payer's credit card will be charged when each invoice and report are mailed out, which is typically every thirty (30) days unless otherwise mutually agreed upon. The Patient Advocate's services will be billed at a rate of $100 per hour.

The Payer and the Client, if different people, may terminate PCM's services at any time and PCM may terminate its services at any time for the nonpayment of any invoice or if PCM deems there to be a breakdown in the relationship between the Patient Advocate and the Client, Payer and/or family members.

Patient Advocate services include meeting the client for an initial evaluation, attending physician appointments, coordinating home care, durable medical equipment, transportation, physical and occupational therapy, and OT evaluations of the client's home. Patient Advocates obtain needed prescriptions during appointments and assist in getting prescriptions filled, if needed. Patient Advocates also obtain medical records from the Client's treating physicians, therapists and other providers. Patient Advocates provide updates after appointments via phone or email to the Payer and provide an initial evaluation report after the first meeting with the client, monthly status reports, and a closure report at the conclusion of services. Payer understands that the aforementioned Patient Advocate services cannot be provided if the Client refuses to sign an Authorization for the Release of Medical Information. Payer further understands that the Patient Advocate does not perform any hands on care.

If the Payer would like to restrict any of the aforementioned Patient Advocate services set forth above, please set forth the restrictions here in detail:

Enter Security Code :

Patient Advocates serving Detroit, MI, Metro Detroit, Lansing, MI, Kalamazoo, MI, Battle Creek, Monroe, MI, Grand Rapids, MI, Holland, Benton Harbor, Muskegon, Ludington, MI, Jackson, Flint, Bay City, Saginaw, Port Huron, Ann Arbor, MI, Midland, Mount Pleasant, MI, Traverse City, MI, Alpena, Gaylord, Grayling, Sault Sainte Marie, MI, Marquette, MI, Escanaba, Iron Mountain, Houghton/Hancock, MI