Client Intake Form

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Office Billing and Insurance Policy

Payment is due at the start of each session unless previous arrangements have been made with our office. You are financially responsible for all services not covered by the insurance company. In the event your insurance company sends any payments directly to you for services rendered by North Shore Behavioral Health: it is your responsibility to forward these payments directly to us along with a copy of the explanation and benefits. North Shore Behavioral Health Policy states that if a scheduled appointment is not canceled within 24 hours of the appointment the patient is responsible for the session, not the insurance company. The Session fee consists of your normal co-payment plus any balance that would have been paid by the insurance company. There is a $30 bank fee for all returned checks. No post‚Äźdated checks will be accepted. Should your account become delinquent, North Shore Behavioral Health may deem it necessary to place your account with an attorney or agency for collection. I agree to pay all reasonable collection fees in addition to the amount owed for services rendered.

Emergencies

In the event of an emergency please contact us by phone or follow the crisis plan we establish which may include going to the nearest emergency room.

Statement of Understanding

I hereby authorize, to release to my insurance company or its representative, any information regarding my treatment, including diagnosis, necessary to process my insurance claim. I hereby assign all my rights to benefits payable by my insurance company to North Shore Behavioral Health Services, LCSW P.C. and thereby authorize and request my insurance company to pay my benefits directly to North Shore Behavioral Health Services, LCSW P.C. I verify that the above information is correct and accurate and I understand if I have out-of-network benefits that I will be responsible for the payment when services are rendered and will be reimbursed from the insurance company. I have read and understood this information sheet and informed consent.