Acknowledgement of Receipt of Professional Disclosure Statement and Informed Consent
SIGNATURE BELOW INDICATES THAT YOU HAVE REVIEWED THE AGREEMENT TITLED “PROFESSIONAL DISCLOSURE STATEMENT” AND YOU AGREE TO ITS TERMS. THIS DOCUMENT INFORMS YOU ABOUT MY BACKGROUND, DISCLOSES MY PHILOSOPHY OF THERAPY, AND INFORMS YOU OF POLICIES, PROCEDURES, LEGAL AND ETHICAL CONSIDERATIONS. THE LATEST PROFESSIONAL DISCLOSURE STATEMENT IS AVAILABLE ON MY WEBSITE UNDER “DISCLOSURE STATEMENT”.
Acknowledgement of Receipt of Privacy Notice
Please be sure to provide your insurance card at our first session. If you do not have your insurance card, you will need to pay in full for the appointment. A refund will be issued if the insurance is successfully billed at a later date.
I authorize the release of all medical records to my insurance company. I further authorize insurance payments to be made directly to Anne M. Coleman, LCSW. I understand co-payments, deductibles, self-pay charges are due at time of service regardless of whether the guarantor is present. Charges for services provided between appointments are due at the next appointment or when billed.
For managing account information and for convenience I am able to provide a monthly statement of charges. If you choose to use your insurance, I am glad to file the proper paperwork. You will be responsible for the remaining balance not covered by insurance – such as copays, co-insurance and sometimes deductibles. All patients must provide a valid credit card to guarantee payment for services. The guarantor may also elect to authorize that the weekly charges for my services be automatically posted to a designated credit card at the end of each week.
Credit Card information is required