Billing Information

Billing Information

MySpectrum
Primary Insurance
Insurance Name:*
Policy #:*
Group #:
Subscriber Name:*
Subscriber Date of Birth:*

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Date
Subscriber SSN:*
Subscriber Address:*
Street, Street 2 (Optional), City, State, Zip Code
Subscriber Phone Number:*
Secondary Insurance
Insurance Name:
Policy #:
Group #:
Upload Front of Insurance Card:*

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Upload Back of Insurance Card:*

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Subscriber Name:
Subscriber Date of Birth:

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Subscriber SSN:
At MySpectrum Counseling & Coaching, we require keeping your credit or debit card on file as a convenient method of payment for the portion of services that your insurance doesn’t cover, but for which you are liable. Without this authorization, a billing fee of $15 will be added to your account for any balances that we must attempt to collect through mailing monthly statements. Furthermore, an "outstanding balance" charge of 1.5 percent of the total bill will be added for each month that the bill remains unpaid.

Your credit card information is kept confidential and secure. Co-payments will be charged to your account after your therapy session. Co-insurance payments to your card are processed only after the claim has been filed and processed by your insurer, and the insurance portion of the claim has been paid and posted to the account.
I (we), the undersigned, authorize and request MySpectrum Counseling & Coaching to charge my credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility. This authorization relates to all payments not covered by my insurance company for services provided to me by MySpectrum Counseling & Coaching This authorization will remain in effect until I (we) cancel this authorization. To cancel, I (we) must give a 60-day notification to MySpectrum Counseling & Coaching in writing and the account must be in good standing.
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Signature:*

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Date:*

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Billing Information

Primary Insurance

Secondary Insurance