Clone of 5. Third Party Payer ROI

Third Party Payer Release of Information

Please complete the form below prior to your first appointment with a clinician at Faithful & True. If you need help or have any questions, please call the office at: (952) 746-3880.
Client Name*
First and Last
I, the client, grant permission for the individual listed below to provide payment for services I am receiving at Faithful & True.
Third Party Payer Name*
First and Last
Third Party Payer Phone Number*
Client Signature*

Clear
Should be Empty:

Third Party Payer Release of Information