NOTE:

We do not get involved with disability determination, custody studies, or handle any and all legal or court related issues. We do not provide prescriptive letters for emotional support animals and we do not complete disability and/or FMLA paperwork.

Sorry, we are unable to offer you an appointment at this time. 

We do not get involved with disability determination, custody studies, or handle any and all legal or court related issues. We do not provide prescriptive letters for emotional support animals and we do not complete disability and/or FMLA paperwork.

Before you begin completing this form, please be sure that you have your insurance card available, if you plan to use insurance to pay for your services. 

Also, if you are unable to finish this form completely, there is an option to save the form so that you can finish it at another time. (Note: this feature may not work on all browsers or all mobile devices.)

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If parents are not together (there is a separation, divorce or custody agreement), we require consent from BOTH of the minor's parents or legal guardians PRIOR to scheduling an intake appointment.

Each parent or legal guardian MUST complete and sign the electronic Counseling Policies & Consents.

Upon receipt of this completed form, we will send electronic Registration form to Parent 2 listed on this form via secure link using the email address provided.

In the event that only one parent has SOLE LEGAL custody, we may require supporting court documentation.

Most insurance companies do not cover more than one therapy appointment on the same day. Be sure to not schedule therapy appointments on the same day or you will risk denied claims. 

All payments are due at the beginning of each session. We accept Cash, Checks, Credit Cards or Debit Cards & HSA Cards. To ensure proper credit, please make checks payable to Rum River Counseling, Inc. or to RRC. There is a $40 service charge for returned checks. Thereafter, payment will only be accepted in the form of cash, credit card or money order. Minors accompanied by an adult other than a parent or guardian, or for unaccompanied minors, charges must be pre-authorized to an approved credit card or paid by cash or check at the time of service.

Please note: While we are in network providers with most major insurance companies, including Medicaid (MA), we are NOT Medicare providers and payment for services would need to be Self Pay only. 

If you have insurance and elect to opt out of using your insurance, you must sign an Election to Self-pay form. By signing the Election to Self-pay form, you understand that we will not be filing a claim with your insurance company and any payments you make will not be credited toward satisfying any deductible under your health insurance plan. If you wish to revoke this election and resume billing your insurance carrier, you must sign & submit the Revocation of Patient Election to Self-Pay for Services form. Rum River Counseling will not submit billing to your insurance carrier for previously completed self-pay visits.​

The Good Faith Estimate is a mandate implemented January 1, 2022 by the Federal Government. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services to prevent "surprise" medical billing and has been applied to all medical providers and facilities. It "forces" medical providers to list fees clearly to clients.

Rum River Counseling has always provided transparency in our billing practices by displaying our fee schedule within our Counseling Policies.

Please know that this form does not change any agreements you have already made with us with regard to self pay. Your review of this form and signature is required so that we can demonstrate our compliance with the mandate.

Thank you!

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.

Coverage Responsibility

Our verification of your benefits cannot guarantee accuracy of information received from insurance representatives. It is your responsibility to know what your insurance plan covers and what your financial responsibility is.

You must notify RRC immediately if there are any changes to your health insurance coverage by visiting our website at www.rumrivercounseling.com and completing the online Update Registration Information form or by calling our office at (763) 482-9598.

If your insurance does not pay for your visit within 90 days, you will be financially responsible for payment and asked to handle the claims directly with the insurance company. You are responsible for any and all denials from your insurer regardless of the reason for the denial.

In compliance with our contracts with your insurance company, a copy of your insurance identification card and you or your legal guardian’s driver’s license/State ID is required.

A valid credit card on file is required for all clients for any balances or missed appointments (see Counseling Policies re:Missed Appointments). We require a non-HSA credit card on file as a back-up to any HSA card. The authorized cardholder must complete and sign the credit card authorization. To update the credit card on file, the link to our secure Credit Card Update form is available on our website www.rumrivercounseling.com current clients tab.