Please complete the following three pages in their entirety.
Assignment and Release:
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 understand and agree to the above Assignment and Release statement.
Check boxes below that apply:
Traumatic Brain Injury
Attention Deficit Disorder
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