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.

 

 

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS FOR INSURANCE

 

 

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Document name: Contact Information Intake Form
lock iconUnique Document ID: 562f610da76a598973b1bce186f534d909ff5b4d
Timestamp Audit
August 25, 2020 11:08 am ESTContact Information Intake Form Uploaded by Leslie Roberts - learningsolutions@learningsolutionsls.com IP 96.39.16.94
October 5, 2020 12:48 pm EST Document owner leslie@learningsolutionsls.com has handed over this document to lroberts@learningsolutionsls.com 2020-10-05 12:48:10 - 96.39.16.94