Client Demographic and Agreement for Payment & Financial Responsibilities

Who referred you?

I would like to be placed on the Care and Counseling mailing list to receive newsletters and other center information.

Insurance (The office will need a copy of both sides of your insurance card.)

**If I fail to obtain authorization, I am responsible for payment to TMG for the denied session.

**If I fail to obtain authorization, I am responsible for payment to TMG for the denied session.

(Please upload copies of your Insurance card (front and back), Identification (front and back).

1. I am responsible for obtaining all authorizations and for all charges not covered. I understand that I am responsible for charges not covered or reimbursed by the above agents. I agree, in the event of non-payment, to assume the costs of interest, collection and legal action (if required and waive confidentiality for this purpose).
2. My therapist may discuss accommodations in special circumstances (i.e. video therapy, phone sessions); it is my responsibility to determine insurance coverage for these sessions or to cover the cost of the service at the agreed-upon rates.
3. My therapist may discuss accommodations in special circumstances (i.e. video therapy, phone sessions); it is my responsibility to determine insurance coverage for these sessions or to cover the cost of the service at the agreed-upon rates.
4. I authorize TMG staff to communicate with my insurance company for the purpose of claim verification and authorization for services, including a diagnosis code, and for my insurance carrier to release information regarding my coverage to TMG. I authorize the release of any medical or other information necessary to process this claim.
6. My right to payment for all services are hereby assigned to TMG. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made directly to me or my representative, I will endorse such payments to TMG.

By signing I indicate that I have been notified of my responsibilities for all fees, co-pay/session rate, late cancellation (<24 hours’ notice) and no shows I may be responsible for, and that I agree to pay those promptly.
I have read the above statements and accept the terms.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

HEALTH HISTORY

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.