Online Registration Form

Ephesians Professional Counseling

REGISTRATION INFORMATION

INSURANCE INFORMATION

Please update if the Policy Holder's information is not the same as the client's

By entering my initials below I understand that Insurance coverage is not a guarantee of benefits and that determination will be made at the time the claim is received. I also understand that I am responsible for the balance if the claim is denied and also for any co-insurance or annual deductible that is applicable. All payments are due at the time of service. I also understand that I am responsible for all appointments and I will be charged a fee of $65 unless I give 24 hours’ notice of cancellations. Late fees are due at the next appointment.

EMERGENCY INFORMATION

Who to contact in case of emergency

Assign and Release

I authorize payment of Medical Benefits to this facility/provider. I authorize release of any medical information necessary to process the claim and/or I also request payment of government benefits either to myself or party who accepts assignment.