Insurance & EAP Claims

Fields marked with an * are required.

By signing below, I consent to the release of any personally identifiable health information necessary to conduct treatment, payment, or other health care operations on my behalf & requests that payment benefits be sent to the provider, Family Services Center. By signing below, the responsible party agrees to all terms & conditions heretofore discussed.

Signature of Responsible Party *

Date *

Name of client (If client is younger than 14 years of age)

Date

By signing below, you agree to these terms & consent to the release of any personally identifiable health information necessary to conduct treatment, schedule appointments, arrange payment, coordinate other health care operations on my behalf, request payment benefits be sent to the provider, Family Services Center, & consent to the release of any personally identifiable information to

Name

By signing below, the responsible party agrees to all terms & conditions heretofore discussed.

Signature of Responsible Party *

Date *

Name of client (If client is younger than 14 years of age)

Date

Agreement to Pay Balance if Insurance Does NOT Pay

By signing below, you understand & agree to these terms. I am responsible for the remainder of my $100.00 per hour fee should my insurance provider not pay for my sessions. I understand that my insurance may pay all, part, or none of the fee for counseling depending on the diagnosis & whether or not I have met my yearly deductible. If I am unable to pay my balance, I agree to work with Family Services to reconcile with a payment plan option.

Signature of Responsible Party

Date

Signature of Responsible Party (If client is younger than 14 years of age)

Date

Provider/Carrier *

Policy Number *

Policy Holder's Name *

Policy Holder's Date of Birth *

EAP Information (If you are an EAP client) *If your EAP is authorized by Tricare we need a MD referral letter.*

EAP Provider

EAP Authorization Number

Number of Sessions Authorized

Message