Insurance Authorization Form for Therapy Clients at Barnum Counseling
This form appears here so you can review it in advance of completing it. You cannot complete it here. To download and print this form for completion, click here:
INSURANCE AUTHORIZATION FORM
Client Name:
Date of Birth (DOB):
Primary Insurance Insurance Company:
Phone Number:
Address:
Employer/Plan Name:
Phone Number:
Name of Policy Holder:
Date of Birth of Policy Holder:
I.D. Number:
Group Number:
Secondary Insurance (if applicable) Insurance Company:
Phone Number:
Address:
Employer/Plan Name:
Phone Number:
Name of Policy Holder:
Date of Birth of Policy Holder:
I.D. Number:
Group Number:
1. I give Barnum Counseling (Kane County Counseling Services, LLC) permission to release my name, date of birth, mental health diagnosis, treatment plan, date of service, and service type received from Barnum Counseling only as required by my insurance company in order to process my claim.
2. I understand that I have a right to review the information to be released. I understand that signing this form is not a required condition of receiving services from Barnum Counseling – that self-pay options outside of insurance are also available.
3. I understand that Barnum Counseling will submit a mental health diagnosis (from the Diagnostic and Statistical Manual, 5th edition) for the person identified as the patient on the insurance claim form.
4. This authorization to release information expires (one year from today):
Client Signature (age 12+):
Date:
Parent/Guardian Signature (if applicable):
Date:
You have the right to withdraw this release in writing at any time.