CLIENT INFORMATION FORM. In order to accurately submit claims for services to your insurance company it is essential that you present a current insurance identification card and the client information form must be filled out completely and accurately. Any omission of necessary information will result in your being responsible for the charges for services you receive. In addition, you are solely responsible for notifying the office PRIOR to your scheduled appointment with any changes in your insurance coverage and/or will be responsible for immediate payment on any service that is denied or not covered by your insurance company including, but not limited to all deductibles, co-insurances, and co-payments. I have read and understand the above statement. Client Signature: Date: Parent Signature: Date:
Appears in 2 contracts
Sources: Therapist Client Services Agreement, Therapist Client Services Agreement