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Assignment and Release
I understand and agree to the following Assignment and Release statement:
I certify that the insurance policy information provided for myself and any of my family members is current and correct. I approve the assignment of benefits to the named provider, Marilyn Pearlman, LCSW. I understand that I am fully responsible for all charges for services rendered, regardless of whether my insurance ultimately pays the claim. I authorize the provider to release all necessary information in order to secure payment for services, and I approve my signature below on all insurance submissions. I assume responsibility to procure any and all forms in a timely manner if utilizing EAP benefits provided by my insurance coverage.
I (client/guarantor) understand that:
A no-show or cancellation request in less than the above mentioned times, will be charged in full to my credit account at the private pay rate or the insurance contracted rate. My insurance company will not be billed.
I agree to keep a current charge card on file, and will take responsibility for informing the office should it change. Should I be under the ALMA billing service (Aetna and United Healthcare/Optum plans), I agree to be enrolled in their Auto Payment.
I am responsible to keep all scheduled appointments for myself or family members. Any requests for rescheduling or canceling an appointment requires a minimum of 24 hours notice for current patients and 48 hours notice for new patients. I understand that I must either email, text or contact Marilyn Pearlman directly so I will not incur a charge.
Payment is expected at the time of the appointment. Should I wish to submit an insurance claim for Out-of Network services, I will do so independently along with the prepared receipt. I will make this request known in advance.
I am responsible to keep all personal information up-to-date, which includes my address, email, phone numbers, insurance coverage, and credit card information.
Services provided by Marilyn Pearlman will not be used for any legal matters, nor for supportive documentation of Social Security benefits, disability, worker’s compensation or military review benefits, disability or worker’s compensation.
I give Marilyn Pearlman, LCSW my permission to communicate with my providers given below. She
may also communicate with the listed family members with my knowledge and approval:
Insurance Card and Drivers License
Please submit a FRONT and BACK photo of your insurance card plus a front copy of your drivers license to firstname.lastname@example.org.
I (client/guarantor) agree to the Assignment and Release, Billing Policies, and Client Consent:
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