INSURANCE INFORMATION AND FINANCIAL AGREEMENT

Client Name_________________________________DOB______________Phone_________________

Address____________________________________________________________Zip______________

PRIMARY INSURANCE INFORMATION: (If possible, please contact your insurance company
prior to your first visit to determine your outpatient mental health benefits.)

Insurance Company___________________________________________________________________

Address/Zip______________________________________Phone______________________________

Name of Primary Insured_______________________________________DOB____________________

Insured's Identification #______________________________Group #__________________________

Insured's Address/Zip (if other than client's)_________________________________________________

Employer Name or School Name________________________________________________________

FINANCIAL AGREEMENT:

The fee per session is: $90 (individual) $100 (couples).

Based on preliminary information obtained from your insurance company:

- Your insurance company will pay _________% or $_____________per session.

- You have a deductible of $______________which has/has not been met.

- Your payment/co-payment is $__________per session, to be paid in full at each office visit.

Comments:__________________________________________________________________________

___________________________________________________________________________________

CLIENT OR AUTHORIZED PERSON'S SIGNATURE:

I authorize the release of information necessary to process my insurance claims. I also authorize payment
of any benefits from the insurance company(s) listed above to be paid to Rebecca Hauder, LCPC for
services rendered by her.

I understand that all fees are my responsibility regardless of my insurance status and if insurance money
cannot be collected, I am responsible for the amount due.

I am aware that I am responsible to pay for missed appointments and late cancellations (with less than 24
hours advance notice).

I understand that if my account becomes delinquent over 90 days and no payment schedule has been
arranged with Rebecca Hauder's Office, the account will be turned over to a collection agency which may
affect my credit report.

Signed_________________________________________Date______________