Client Information Form

Please fill this form out as thoroughly as possible. If a particular field does not apply, please indicate this by submitting an “N/A” in that field. If you are using your insurance to pay for your sessions, you will need to complete the part labeled “Section 2” with your insurance info. If submitting electronically, there is also an option to upload a picture of the front and back of your insurance card. If you do not use this option, I will need to get a physical copy of your insurance card at our first appointment. If you are not using insurance, neither “section 2” nor the picture of an insurance card need to be completed, but the rest of the document will need to be completed. Please ensure that you either electronically sign if submitting online or physically sign if you are printing this form out.

Section 1

Today's Date*
DOB
Address

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 information:

Section 2

DOB
Insurance Mailing Address
Accepted file types: jpg, jpeg, gif, png, Max. file size: 300 MB.
Accepted file types: jpg, jpeg, gif, png, Max. file size: 300 MB.

Confidentiality

All information between counselor and patient is held strictly confidential unless:

  1. The patient authorizes release of information with his/her signature.
  2. The patient presents a physical danger to self.
  3. The patient presents a danger to others.
  4. 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.

Financial Terms

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 approved.

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.

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