Insurance Information for Private Practice

Insurance Information for Private Practice

Insurance information from Private Practice Form Preview
CA Insurance Information
  • Communication Apptitude, Inc.

  • Insurance Information

    The information below will help us create an insurance form for you to submit to your insurance company monthly.
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  • Insurance - Primary

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  • Assignment and Release

  • I, the undersigned, certify that I (or my dependent) understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the therapist to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

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