Minor Registration Ages 11-17

1. I have been informed of my rights and if I feel like I have been discriminated against because of race, religion, national origin, sex or age, I may complain to this agency or to the State or Federal agencies listed in the “Notice of Privacy Practices”.
2. I have been informed regarding my rights; have been read the Tennessen Warning; have had my initial questions answered regarding these issues; and have been given the handout “Client’s Bill of Rights”, “Notice of Privacy Practices.” And a copy of the grievance procedure. I understand that I may request further information at any time.
3. I have been informed, and I understand that management personnel reserve the right to attend clinical staffing’s where my case may be reviewed. This is to ensure that appropriate services are being offered and provided and ensure an effective interdisciplinary team approach.
4. By signing this form I am giving “Consent for Treatment.”

□ Each month I will pay a minimum of 25% of the total balance due until all charges are paid.
□ Following each visit, I will pay the charges for that visit.
□ Upon receipt of a monthly statement, I will remit the amount due.
□ I will be responsible for payment for any services denied by my insurance company, including but not limited to deductibles, co-pays and exclusions.
□ I understand that I am responsible for the charges in full, forfeiting my opportunity to be placed on the sliding fee scale, if I do not comply with the following (when applicable):

a. Provide verification of income documentation
b. Obtaining a physician referral when my insurance requires one.
c. Applying for medical assistance and notifying Northland Counseling Center, Inc. (NCC) of disposition if referred.
d. A fee may be charged for any missed appointments which are not canceled at least 24 hours in advance.

I recognize that it is my responsibility to be aware of my insurance benefits and payment by insurance is not guaranteed.

In the event NCC has been unable to collect payment from me for services within a reasonable period of time, NCC then reserves the right to turn the account over to an attorney or collection agency (this may include: address; phone/cell phone number; email, etc.). I understand that interest, finance charges and other costs as allowed by law, will be added to my account. A 15% processing fee will be added to any account sent to collections.