I authorize Dunham Counseling Center, Ltd. to release any medical information necessary to process my insurance claims. (For clients who use their EAP or are doing Business Counseling/Coaching, no information will be released to insurance companies). I request payment of benefits to be made to Dunham Counseling Center, Ltd for services rendered. I understand that I am responsible for any balance not paid by my insurance company. I understand that co-payments and account balances not covered by insurance are due at the time of service.
Your therapist has a late cancellation policy of 24 hours notice. If you do not show or cancel within 24 hours you will be charged. Cancellation fees vary by therapist. Please discuss the cancellation fee amount with your therapist.
The typed signature acknowledges your adherence to the Agreement to Receive Services and also the Payment Authorization.
I have received a copy of or provided access to the online copy of Dunham Counseling's HIPAA Privacy Policy.
I hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.
