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 Auth Form
Click to download insurance authorization form:
USE OF INSURANCE
I understand that Barnum Counseling is in-network with most major commercial insurance companies in the state of Illinois. As a courtesy, Barnum Counseling will obtain a quote of benefits from my insurance benefits/plan. However, it is ultimately my responsibility to know the coverage and benefits under my individual/family insurance plan. I may be responsible for a deductible, copay, or co-insurance depending on my policy.
In choosing to utilize insurance:
I give Barnum Counseling 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 for the purpose of claims submission or in the event of an audit.
I understand that Barnum Counseling will submit a mental health diagnosis (from the Diagnostic and Statistical Manual, 5th edition – revised) for the person identified as the patient on the insurance claim form in order to process my claim.
I understand that relationship/marriage counseling (i.e. diagnosis code Z63.0 – relationship distress with spouse or intimate partner) is not considered a diagnosis of medical necessity, and thus will not be covered by insurance. If I am interested in couples counseling, I will speak with my therapist about my options and insurance coverage.
I understand that Barnum Counseling and my insurance company have agreed to an adjusted rate to provide me with discounted services. Although my insurance may pay a portion of the cost of the professional services received through this office, if claims are denied and cannot be resolved within 90 days of the date of service, I am ultimately responsible for complete payment of the charges.
I agree to promptly inform Barnum Counseling of any insurance plan changes or updates.
You have the right to withdraw this release in writing at any time.