Patient Information and HIPAA Authorization Form

Why we need this form

Complete our MTBS Patient Information and HIPAA Authorization Form to streamline your insurance approval. This form ensures HIPAA compliance, protects your health information, and enhances collaboration with your doctor and insurance. It enables efficient approval requests for medical tattooing from your insurance company.


Form Completion & Documentation Requirements


Please allow 15–20 minutes to complete the form. Be sure to upload clear photos of your insurance card and driver’s license. You’ll also need to provide contact details for your Plastic Surgeon (or other treating physician who will send medical records) and your Primary Care Physician—including fax numbers for both.


Upload medical documents. For assistance, email claims@mtbs.ink or call 407-574-8383 .


(Note: MTBS cannot submit authorization requests or claims to Medicaid, Medicare with a Supplement Plan, or TRICARE. Some Blue Cross Blue Shield plans may also deny payment. If your insurance is not accepted, MTBS will notify you and provide self-pay options.)

Here's what you can expect from us:


  • MTBS will provide you with a document to request your medical records, along with a Letter of Medical Necessity for your doctor to complete. Once filled out, your doctor will send the records directly to us for your upcoming insurance claims. Please note, it is your responsibility to ensure we receive all required documentation.


  • Your insurance may need two to three approval levels. MTBS will appeal their initial decision if necessary.


  • After your insurance makes a final decision, MTBS will email you to explain any financial responsibilities you may have.  We'll also inform your Artist/Provider about their decision.


  • After scheduling your services with your Artist/Provider, MTBS will email you an invoice requiring prepayment of any financial responsibilities at least seven days before your appointment to secure your visit.


Our process operates on a first-come, first-served basis, with standard processing times averaging eight to ten weeks. Delays may occur due to high demand and complexities with certain insurance companies.  We appreciate your patience if it takes a bit longer we hoped.


What to do:


Please follow the steps below to begin:


Step 1: Allocate at least 20 minutes to prepare AND complete the form.


Step 2: Prepare photos and physician contact details:


  • Take clear, readable photos of your insurance card and driver's license, choosing the smallest image size if available.
  • Make sure you have contact info for your Oncologist OR Plastic Surgeon, AND your Primary Care Physician (PCP), including fax numbers. You may need to call their office.


Step 3: Complete the MTBS Patient Information and HIPAA Authorization Form.


Step 4: Upload, text, or email photos:

  • Provide clear images of both sides of your insurance cards and driver's license or Id with a photo.
  • Upload images into the form, OR text them to 407-574-8383 , OR email them to claims@mtbs.ink (all HIPAA compliant).


For inquiries, email claims@mtbs.ink or call 407-982-4876. Due to demand for our services, please allow 2-3 business days for a response. Kindly note that early or frequent email inquiries regarding approval status may cause delays as we are actively processing approvals.