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Practice in Child, Adult, and Couples Psychotherapy Consultant, Child Health Services
Information you provide here does not constitute a contract between us. It is for initial
administrative only. My practice accepts some forms of insurance. However, it is important to
understand that most insurance plans place limitations on the services they cover. Also, in order
to allow additional sessions, they may require that I periodically discuss clinical information
about your care. I cannot safeguard the privacy and use of information given to insurers. For
this reason, some individuals choose to not use insurance for their psychological care. If you
chose to use insurance, we will verify your coverage. On occasion customer service
representatives may give inaccurate information. Therefore, if you chose to use insurance, it is
in your best interest to inform yourself about which outpatient psychological services are
covered under your plan.
A. I wish to pay for psychological services out of pocket.
B. I wish to access an insurance benefit.



Information about the insurance, if you wish to access an insurance benefit

1. Insurance name
2. Name of subscriber
3. Insurance ID #
4. Group Number (if applicable)
5. Phone number for providers (on back of card)
6. Is there a deductible on your plan?
7. If yes, has it been met?
C. Information about you (and other patient(s) if applicable)
1. Name
Street, City, Zip
2. Name
Street, City, Zip
Please read these important notes: (a) If you are accessing an insurance benefit & there is a
deductible associated with your plan, you may be required to pay out-of-pocket for all
insurance-reimbursable care when the care is provided, until the deductible is met. (b) Payment
for services not reimbursed by your insurance within a reasonable period of time is billed at my
hourly rate. (c) Payment for psychological services not covered by insurance is billed at my
hourly rate. Other important details will be found in the Informed Consent, which will be sent
for your review after payment has been arranged. (d) Accessing your insurance requires that I
assign (and you accept) a psychiatric diagnosis from the code book used for these purposes, the
DSM 5. However, many valid human problems which benefit from psychological services do
not meet the criteria for a psychiatric disorder or diagnosis as defined in the DSM. I cannot
guarantee that the above-named client will meet the criteria for any psychiatric disorder or
diagnosis as defined in the DSM. (e) I cannot guarantee the confidentiality of medical records
held by an insurance company. (f) Please contact me if you have any questions or concerns.
82A Ponemah Road, Amherst, New Hampshire 03031 Phone & Fax 603 672-0777

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