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  • Arizona Psychiatry Change/Update Insurance Form

  • PLEASE NOTE THAT WE ARE NOT IN NETWORK WITH AHCCCS, MEDICARE, TRICARE, WORKERS COMP, OR EAP.

    IF YOU DO NOT SEE YOUR INSURANCE LISTED PLEASE DO NOT FILL OUT THIS FORM AND CALL OUR OFFICE.
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  • Self-Insurance election (e.g.  "self-pay", "self-insured", "out-of-pocket", "cash-pay") requires  notification of applicable laws and policies, as well as your explicit  consent. While Arizona Psychiatry is an in-network provider with many  health insurance companies, we do not currently have relationships with  Medicare/Medicaid (AHCCCS) and some other select private insurers. In  these instances, someone may elect to be self-insured (or pay  "out-of-pocket") when either they do not have health insurance coverage,  when the healthcare provider or practice is "out-of-network", or when  patients explicitly do not want their insurance billed - instead  electing to pay out of pocket at the time of service. Generally, someone  who has health insurance coverage is obligated to submit healthcare  claims to the insurer for reimbursement. If you otherwise have insurance  or other types of health coverage, services received as "self-insured"  will not likely be reimbursed by your insurance carrier or applied to  your deductible, and may complicate your relationship with your health  insurance company. You may want to  discuss this and any repercussions with your insurance carrier before  pursuing this option. By signing below, you are simply acknowledging  that you have read this notification. We will speak with you in more  detail about it later and clarify any questions you may have.

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