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2024 Rum River Counseling Registration Update 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.
42Questions
  • 1
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  • 2

    The Registration Update form is ONLY to be completed by current, active clients who are updating insurance or other registration information.

    If you are a previous client, returning for services, please do not finish this form - instead, complete the Appointment Registration form.  Thank you!

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  • 3
    Please check all that apply
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  • 4
    Please indicate which office(s) you are currently receiving or plan to receive services.
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  • 5
    List all Rum River Counseling office locations that you have received services from:
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    If you are a returning client, please indicate if there is a therapist you wish to return to.
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  • 9
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  • 10
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    Pick a Date
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  • 11
    Please note any address changes.
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • 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
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • 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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  • 15
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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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  • 19
    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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  • 22
    In compliance with our contracts with your insurance company, a copy of your insurance identification card on file is required.
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  • 23
    I, the undersigned client/client legal guardian(s), authorize Rum River Counseling, Inc. to release any medical information to my insurance company which may be deemed necessary in order to process an insurance claim. I authorize my insurance company to assign benefits to Rum River Counseling, Inc. I understand that I am responsible for payment for services rendered by Rum River Counseling, Inc. regardless of reimbursement for these services by the insurance company and that any inaccuracy in information on this form may result in nonpayment by my insurance company. I understand that if my health insurance company has not paid a claim within 90 days of the date of submission, I accept responsibility for payment in full of any outstanding balance and that I must follow up directly with my insurance company for payment. I agree to notify Rum River Counseling, Inc. immediately regarding any changes in my health condition or health plan coverage.
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    In compliance with our contracts with your insurance company, a copy of your insurance identification card on file is required.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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    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.​

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    By signing the Self-pay agreement, you agree and understand that all self-pay services must be paid in full on the date of service.
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    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.
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    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!

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    By signing here, you are confirming that you have been provided a copy of the Good Faith Estimate, as mandated by the No Surprises Act.
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  • 33
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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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  • 35

    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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