My electronic signature indicates indicates agreement to the following: I authorize the release of my medical/mental health/substance use information or other information necessary to the insurance company and to the provider’s billing service in order to process any and all pre-authorizations and/or claims regarding services rendered. All insurance plans that cover the identified client are listed on this intake form. I agree to inform Heidi Weipert PLLC of any changes to insurance coverage and benefits. I understand that it is my responsibility to provide complete and current insurance data for all services rendered at all times. This includes policyholder data. I authorize payment of medical benefits directly to Heidi Weipert PLLC for services rendered. I agree to be financially responsible for all charges incurred at Heidi Weipert PLLC including deductible, co-payment and/or any other fees incurred and/or denied by my insurance company. I am ultimately responsible for all charges and fees incurred at Heidi Weipert PLLC regarding the identified client. I understand that failure of payment may result in collection proceedings via a collection agency or small claims action. I understand that I am responsible for all fees associated with the collection process against my account whether it is via a collection agency and/or small claims action. Typing my name in the area provided is the legally binding equivalent of my handwritten signature.