Patient Information and HIPAA Authorization Form

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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
407-982-4876.

(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.)

Start MTBS Patient Information and HIPAA Authorization Form

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:

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

  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.

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

  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 407-205-8655, 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.

Use Your Insurance for Medical Tattooing

Our goal is to receive approval for you to use your in network benefits, even though your medical tattoo artist is out of network. Your insurance company may approve this when the service is medically necessary and there is no appropriate in network medical provider available to perform it.

Your insurance company may still require you to use your out of network benefits, but that is not the outcome we are requesting.

How Long Does the Process Take?

The full process typically takes 6 to 8 weeks from the date you submit this form, including the time needed to receive your medical records. However, it may take longer.

The response times of your doctor's office and insurance company are outside our control. Appeals can also extend the timeline, and some insurance companies take several months to provide a financial agreement.

If we have not worked with your insurance company before, additional time may be needed to learn its unique process and identify the correct departments or contacts. This can delay the financial agreement because we may not have an established contact who can provide updates.

What Happens Next?

  • 1 Medical Records We request your medical records and a Letter of Medical Necessity from your doctor.
  • 2 Insurance Review We verify your benefits and submit the required authorization requests for medical tattooing and the use of your in network benefits.
  • 3 Insurance Responses You may receive approval and denial letters during different stages of the process. These letters should not be considered final until MTBS reviews them.
  • 4 Appeals If a request is denied, we will review the reason and handle an appeal when appropriate.
  • 5 Financial Agreement If approved, we may need to obtain a written financial agreement from your insurance company. This agreement confirms the approved payment terms and provides the assurance needed before you schedule.
  • 6 Final Confirmation We will email you when the process is complete, explain any amount you may owe, and let you know when you can schedule directly with your artist.
  • 7 Patient Payment If you have a financial responsibility, MTBS will send your invoice approximately 7 to 10 days before your appointment.

Please Do Not Schedule Yet

Do not schedule your appointment until MTBS confirms that the insurance process is complete. An authorization or approval letter does not always mean that all required steps have been completed.

Please contact MTBS, not your medical tattoo artist, for updates. Your artist does not have access to your insurance case or its status.

Calling your insurance company may not provide an accurate update because customer service representatives may not be aware of every stage required before you can schedule.

If you need to receive treatment within a specific timeframe, the insurance process may not be the best option. You may choose to self pay instead, but please notify MTBS before scheduling. We will provide your self pay fee and continue to manage the billing process.

For assistance or updates, contact claims@mtbs.ink

or 407 982 4876. Please allow 1 to 3 business days for a response.

We appreciate your patience throughout the process.

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