Insurance for treatment is billed through this office as a courtesy to our patients. Please understand that this in no way
takes away the responsibility for payment from the individual patient. An estimate of the patient’s portion/co-payment
will be given to the patient and payment of this amount is expected at the time of service. By requesting insurance
billing from this office, you authorize the release of any information for claims, certification/case management/quality
improvement, and other purposes related to the benefits of your health plan. You also authorize direct payment of
benefits to the supplier of services being billed. If you would like us to bill your insurance, please provide the following
All information between counselor and patient is held strictly confidential unless:
- The patient authorizes release of information with his/her signature.
- The patient presents a physical danger to self.
- The patient presents a danger to others.
- Child/elder abuse/neglect are suspected.
In the latter two cases, we are required by law to inform potential victims and legal authorities so that protective
measures can be taken.
Upon verification of health plan/insurance coverage and policy limits, your insurance carrier will be billed for your
sessions. Your Provider will be paid directly by the carrier. The patient will be responsible for any applicable
deductibles and co-payments. If your insurance determines you are not eligible for services provided and you choose to
proceed with service, you are responsible for full payment.
For those without health plan/insurance coverage, payment arrangements should be made prior to your first visit.
In the event of default of payment, the balance of the account is due in full. The patient will be responsible for any
reasonable court costs, attorney fees and/or collection fees incurred.
Appeals And Grievances
In the case of those with managed care health plans, I acknowledge my right to request reconsideration in the case that
outpatient care (number of visits) are denied certification. I understand that I would request an Appeal through my
Provider and that I risk nothing in exercising this right. I also understand that should I choose to continue treatment
without authorization by my health plan and my Appeal is denied, I will be responsible for payment of sessions not
I also acknowledge that I may submit a Grievance to the Provider or Clinical Group Administrator at any time to register
a complaint about any aspect of my care. If I am not satisfied with the response I receive, I may submit the Grievance
directly to my insurance carrier.
Consent For Treatment
I further authorize and request that Nathaniel Marshall, LPC, carry out behavioral health treatments, and/or diagnostic
procedures which now or during the course of my care as a patient are advisable. I understand that the purpose of these
procedures will be explained to me upon my request and be subject to my agreement. I also understand that while the
course of therapy is designed to be helpful, it may, at times, be difficult and uncomfortable.
Release Of Information
I authorize the release of information for claims, certification/case management/quality improvement, and other purposes
related to the benefits of my Health Plan. (Release of information to provider, family, etc., requires separate form).
I understand and agree to all of the above information.