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RRC Current Client Internal Referral Form

Note: If you are experiencing a medical emergency please dial 911 to contact local emergency response personnel. This form is not to be used in the event of a crisis or emergency.
33Questions
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  • 4
    Please check all that apply
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  • 5
    Please indicate which office(s) you are currently receiving or plan to receive services.
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  • 6
    List all Rum River Counseling office locations that you have received services from:
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  • 10
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    Pick a Date
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  • 11
    Please note any address changes.
    • Please Select
    • Alabama
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    • Maldives
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    • Martinique
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    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
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    • Panama
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    • Philippines
    • Pitcairn Islands
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    • Qatar
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    • Rwanda
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    • Samoa
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    • Trinidad and Tobago
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    • United Kingdom
    • United States
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    • Vatican City
    • Venezuela
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    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Please note any phone number changes or an additional phone number you want added to your account.
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    Please note any changes to the email we have on file for you.
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  • 14
    Please read the options carefully and select the option(s) that best describes your update.
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    If there is any overlap between when the previous policy termed and the new policy began, there may be issues with coordination of benefits. You will want to be sure that you have contacted both policies so that they are aware of the other.
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    Coordination of Benefits
    Coordination of Benefits is also called COB. It is your responsibility to update the COB with each insurance company.

    If you have coverage with more than one insurance company, then the COB rules determine which policy will be the primary, then secondary insurance etc., to ensure that your claims are paid by the correct payer respectively.

    Please note, some insurance companies require annual COB updates even if you or your dependents do NOT have other coverage.

    To update COB, simply call the Member Services phone number on the back of your insurance card(s). You are responsible for claims denied due to COB.

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    Primary Policy Information - PLEASE complete each box. Missing info may delay the verification process.
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    If there is a secondary insurance policy, this information is required. Please be sure that each insurance company is aware of the other policy or your claims will deny.
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    PLEASE complete each box. Missing info may delay the verification process.
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    In compliance with our contracts with your insurance company, a copy of your insurance identification card on file is required.
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    In compliance with our contracts with your insurance company, a copy of your insurance identification card on file is required.
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    I, the undersigned client/client legal guardian(s), acknowledge that I am consenting to treatment/services at Rum River Counseling, Inc. and have been provided with a copy of, and that I fully understand & agree to all of the terms and conditions of the Counseling Policies, including the Notice of Privacy Practices (HIPAA).If I have questions, the information has been explained and/or summarized for me.
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  • 26

    We require a MINIMUM of 24-hour advance notice for appointment cancellations to avoid a charge. Our late cancellation fee is $100 and the no-show fee is $150. It’s important to remember that insurance will not pay for missed appointments, so you will be responsible for the full fee, not just a copay. It is up to your therapist’s discretion to require more than 24-hour notice or to charge a higher rate for missed appointments. You are responsible for appointments you schedule whether you receive automated reminders or not.

    This cancellation policy is important for a counseling practice because, while a medical doctor can see 30+ patients in a day, your therapist generally sees a maximum of 6 or 7. Your therapist reserves this time specifically for you (a full hour of time for the session and clinical notes). If you cancel with less than a full 24-hour notice, they won’t be able to fill that time slot, and will lose an entire hour from their work schedule.

    Our cancellation policy is not a penalty or a punishment. The reality is, if you are in counseling long enough, at some point you might forget about an appointment, or something will come up in your schedule that will result in you missing an appointment. Maybe you’ll need to work late. Maybe you’ll get a sudden onset of the flu. Maybe your kids will have doctor appointments, or your car will break down, or something unavoidable will come up. In return, understand that scheduling an appointment is much like buying tickets to an event. If you miss the event, it doesn’t matter why you missed it, or even if it was your first time, you can’t turn in your tickets for a refund.

    If you are unable to make it to an in-person appointment, it might be an option to see your therapist via teletherapy. This is up to the discretion of your therapist, as some therapy modalities are best processed in person.

    Same day scheduling is an alternative if you are unable to commit to a reserved appointment time. Because we have many people who are waiting for appointments, clients who fail or cancel even one appointment without 24-hour notice risk being able to schedule ongoing reserved appointments and will be subject to the therapist’s “same day” availability. With same day scheduling, no appointment is reserved for you, and you will need to contact your therapist the morning of the day you would like to meet to see if they have any available times that day to see you.

    Successful on-going therapy requires a commitment on the part of the client. It is important that you keep your appointment if at all possible.

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    We can only reserve appointments with clients who are committed to attending scheduled appointments and who understand and agree to the missed appointment fees if 24 hour notice is not provided. This policy is part of the terms & conditions of the Counseling Policies.
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    Or the person completing this form on behalf of a client.
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