ADMIN Form for: Payment Policy for Assessment Services through Insurance
Responsible Party
Client Name
Client DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Insurance Information
% Amount of Assessment Fees
Name of Insurance Company
Deductible Amount
Co-Payment Amount
Number of Direct Contact Hours
(testing, interview, etc.)
Number of Indirect Hours
(review of records, scoring, preparation of report)
Submit
Should be Empty: