I authorize the release of any medical or other information necessary to process my insurance claim. I have received disclosure information from Emilie Moreau regarding her training and policies regarding fees and payment, confidentiality, cancellations and emergencies and I agree to abide by these policies and procedures. I understand that if my health insurane company does not cover the servcies I receive from Emilie Moreau, I will be responsible for paying the associated fees in full. I understand it is my responsibility to determine whether or not my health insurance will cover outpatient mental health services with Emilie Moreau. I have also received information concerning unprofessional conduct for allied mental health professionals according to Vermont statutes and a Notice of Privacy Practices regarding the Health Insurance Portability and Accountability Act (HIPAA).