I hereby authorize KATHRYN WALKER, LCSW, whom I know as Therapist KATE WALKER, LCSW to contact my insurance carrier in order to determine eligibility for Therapy Services. I understand that my insurance will be billed for services rendered by KATHRYN WALKER, LCSW. I agree that if my insurance carrier issues a check in my name for reimbursement for services rendered, I will within five days of receipt of this check make payment in the amount of said check to the therapist.
The following also applies to the use of my insurance to cover the cost of services rendered:
Authorization to Release Medical Information for Billing
• I hereby authorize the release of any information regarding services by the Therapist to process insurance claims and allow a photocopy of my signature to file insurance claims.
Assignment of Insurance Benefit
• I hereby authorize irrevocably assignment of payment for my benefits due me for the services rendered by the Therapist made directly to the Therapist.
Financial Responsibility
• I understand that if I am utilizing an “out of network” provider for the services rendered by the Therapist, that regardless of insurance benefits, I alone am fully financially responsible for the fees for the services rendered. I agree to pay any past due amounts if collected as a result of the Therapist being “out of network”
Authorization for the Release of Medical Information for Treatment
• I hereby authorize the above Therapist to obtain copies of my medical records as they pertain to my mental health for the purpose of evaluation and treatment