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Contact Information Intake Form

FINANCIAL POLICY

Appointments canceled with less than 24-hour notice will be charged to me at the full fee per hour.

Secondary insurance will be billed as a courtesy, but I am responsible for the entire balance of services performed regardless of whether there is insurance coverage.

I understand and agree to the above stated financial policy

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS FOR INSURANCE

I authorize the release of any medical or other information necessary to process insurance claims.

I authorize payment of medical benefits to my provider for services performed.

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I understand this is a legal representation of my signature

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Timestamp

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August 25, 2020 11:08 am EDT

Contact Information Intake Form Uploaded by Leslie Roberts - learningsolutions@learningsolutionsls.com IP 96.39.16.94

October 5, 2020 12:48 pm EDT

Document owner leslie@learningsolutionsls.com has handed over this document to lroberts@learningsolutionsls.com 2020-10-05 12:48:10 - 96.39.16.94