My signature below indicates that I have read, understand, and agree to the terms of the Heart and Solutions Consent to Treatment including privacy practices, patient rights, and patient financial responsibility. By signing this document, I am providing consent to be treated by Heart and Solution for outpatient therapy and/or Behavioral Health Intervention Services. I understand that insurance billing is provided as a courtesy and that I am financially responsible to Heart and Solutions, LLC for all charges resulting from my treatment. It is my responsibility to notify Heart and Solutions, LLC of any changes in my health care coverage. While Heart and Solutions, LLC verifies my insurance eligibility, exact benefits cannot be determined until the insurance plan receives the claim. I agree to accept financial responsibility for all services received by me or by my dependents. I authorize direct payment from my health insurance plan to Heart and Solutions, LLC for all services provided to me or my dependent. This is a direct assignment of my rights and benefits under this policy. A photocopy of this assignment shall be considered as effective and valid as the original. We have discussed the privacy practices, and I understand that I may request a copy at any time in the future. I consent to accept these policies as a condition of receiving mental health services.