Client Insurance Form

Instructions From Practice: Please provide your insurance information, then submit below.

    Insurance Policies

    I do not have or do not want to use insurance benefits. I will be responsible for all charges related to the services rendered.

    Policy Information

    Policy Information

    Acknowledgement

    I authorize Jackson Marriage and Family Counseling Services to release information to the insurance companies provided on this form in order to submit insurance claims on my behalf. This authorization extends to the extent necessary to obtain payment for the services provided to me, and includes authorization to release information about mental health, substance use, or HIV diagnoses as required. In consideration of the services provided to me, I assign all benefits to Jackson Marriage and Family Counseling Services if accepted, and authorize my insurance companies, Medicare, or other third-party payers to make payments directly to Jackson Marriage and Family Counseling Services and its affiliates. I understand that I remain responsible for all amounts due by me, including (but not limited to) copays, coinsurance, deductible amounts, and all services not covered by my insurance plan (including those for which I fail to obtain prior authorization), and mutually agreed-upon services or fees that are deemed not medically necessary.

     

    Confidentiality & Privacy Policy

    The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without the client's permission. However, clinicians have mandated reporters and are required by law to contact the authorities if children, elders, and other vulnerable community members are at risk of harm. Such as:

    • Suspected child abuse or dependant adult or elder abuse

    • If a client is threatening serious bodily harm to another person

    • If a client intends to harm himself or herself and efforts to obtain their cooperation for prevention and intervention are futile