Adult Registration Form

I authorize Northland Counseling Center, Inc. to release information to my insurance company regarding my treatment and I permit a facsimile or photographic reproduction of this athorization in place of the original. This could include my Social Security number, diagnosis, prognosis, dates of treatment, narrative notes, and types treatment. This is for the purpose of validating claims submitted to stated insurance carrier. I also athorize stated insurance carrier to make payments to Northland Counseling Center, Inc. for all insurance benefit to which I or my dependents are entitled for services received. I understand that this consent will terminate one year from the signature date unless I choose to revoke it earlier.

I understand that I am responsible for the charges in full if I do not maintain coverage for which I am eligible or fail to provide insurance information and/or income verification (if interested in fee reduction).

I recognize that Northland Counseling Center, Inc. cannot gauruntee payment of charges by any particular insurance carrier. If I have questions regarding coverage, I will contact my insurance company.

In the event Northland Counseling Center, Inc. has been unable to collect payment from me for servces within a reasonable period of time, the Center then reserves the right to turn the account over for colletion of my bill. A 15% processing fee will be added to any account sent collection.

I affirm that the information on rever is accurate I am aware of my financial responsibilities and agree to the payment terms. I authorize the release of information to my insurance carrier(s). If my address, phone number, financial status, or insurance coverage changes, I will notifiy Northland Counseling Center, Inc., and an update of the agreement may be renegotiated.