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!

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.

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!

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.