Contact and Billing Information

Insurance Information
Primary Insurance Company*
Phone #*
Subscriber Name*
Subscriber DOB*

MonthDayYear
Date
Contract Number*
Group Number*
Subscriber Address*

Address

Street Address Line 2

CityState / Province

Zip
I give my consent to allow coordination of care with this insurance company and this counseling office to pursue payment for my sessions. I know that the bill is my responsibility and the contract is between me and my insurance company. I am responsible for any co-payments and deductibles as required by my insurance company.

Credit Card Information/Health Savings Account
Credit Card Information/Health Savings Account

After the session you will receive a secure link to the billing program that is HIPAA approved, called IvyPay. You will be requested toenter a credit card to pay for anything that insurance does not pay. This will be automatically billed after receiving payment from theinsurance company (sometimes will take 2-4 weeks). This would be where you could enter your HSA accounts. If you need additionalreceipts, please inform.

Signature
I understand that missing a scheduled appointment without 24-hour cancellation notice will result in a $30 charged to this credit card.I agree that this credit card will be billed for remainder of the balance after insurance is billed. Rates for sessions are $155 per 50-60minutes for therapy sessions (may be higher for initial and planning sessions). I give my consent for treatment for myself (and/or anyfamily members or children).
Client/Guardian Printed Name
Client/Guardian Signature *

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Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
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