Please do not hit the browser's back button while filling out the form.

All items marked with a red asterisk must be completed.

If you selected Yes to secondary insurance, please contact the office to provide the information for our records. 

AUTHORIZATION

I hereby give my concent to the therapist at Hope Counseling Inc to provide mental health services to myself and/or family. I understand and agree (regardless of my insurance status) that I am responsible for the balance of the account.

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage and assign directly to Hope Counseling Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Hope Counseling Inc. to release all information necessary to secure payment of benefits. I authorize the use of these signatures on all insurance submissions.

INSURANCE POLICY

Changes made daily among insurance companies, make it impossible for us to accept the responsibility of knowing if your plan dictates benefits, payment, coverage and whom you can and cannot see. As a service to you, we will file your insurance claim. In order for us to file your insurance, please provide all insurance information on the day of your visit. It remains the responsibility of the patient to know his or her own plan. As a service to you, we will call your insurance company for an estimate of what they will pay. It is important to know that any information given over the phone cannot be guaranteed and is only an estimate. If your policy has a copay amount for office visits, that copay is due at time of service. No balances will be carried over.

Please read and sign below only if you have Medicare coverage.

MEDICARE AUTHORIZATION (if client has Medicare)

I request that payment of authorized Medicare benefits be made on my behalf to Hope Counseling Inc. for services furnished to me by Hope Counseling Inc. I authorize any holder of medical information about me to release to the Division of Medicare and Medicaid Services and it agents any information needed to determine those benefits payable for related services.  I understand that my signature requests that payment be made and authorized release of medical information necessary to pay the claim.  If “other health insurance” is indicated in item 9 on the HCFA-1500, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.  In Medicare assigned cases, the therapist agrees to accept the charge determination of the Medicare carrier as the full charge, and non-covered services.  Coinsurance and deductible are based upon the charge determination of the Medicare carrier. 
 

Upon completion of this form, please 

1. Click on Submit below to email the form to intake@hopecounselinginc.com  (preferred), OR

2. Print completed form and bring with you to your first appointment.

3. Please do not hit the browser's back button while filling out the form.

4. All items marked with a red asterisk must be completed.