HIPAA MTBS Patient Information and Authorization Form

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


Allow approximately 15-20 minutes for form completion and take clear photos of your insurance card and driver's license. Provide contact details for your Oncologist OR Plastic Surgeon, AND Primary Care Physician (PCP) INCLUDING FAX NUMBERS FOR BOTH.


Upload medical documents. For assistance, email claims@mtbs.ink or call 407-982-4876.


(Note: We cannot submit requests to Medicaid, Medicare with Supplement Plans (Medigap), or Tricare. Please contact us to confirm your insurance type if unsure. Financial assistance may be available through non-profit partners. Ask your Medical Tattoo Artist for recommendations.)

Here's what you can expect from us:


  • MTBS will provide you with a document to request your medical records from your doctor, who will then forward them to us for your future insurance claims.


  • 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 pre-payment 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 689-710-9457, OR email them to claims@mtbs.ink (all HIPAA compliant).


Step 5: Optional: Upload or email medical documents related to your condition (up to 5 pages). This can speed up the process. The documents don't need to mention medical tattooing specifically.


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.

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