The Registration Update form is ONLY to be completed by current, active clients who are updating insurance or other registration information.

If you are a previous client, returning for services, please do not finish this form - instead, complete the Appointment Registration form.  Thank you!

Coordination of Benefits
Coordination of Benefits is also called COB. It is your responsibility to update the COB with each insurance company.

If you have coverage with more than one insurance company, then the COB rules determine which policy will be the primary, then secondary insurance etc., to ensure that your claims are paid by the correct payer respectively.

Please note, some insurance companies require annual COB updates even if you or your dependents do NOT have other coverage.

To update COB, simply call the Member Services phone number on the back of your insurance card(s). You are responsible for claims denied due to COB.

If you have insurance and elect to opt out of using your insurance, you must sign an Election to Self-pay form. By signing the Election to Self-pay form, you understand that we will not be filing a claim with your insurance company and any payments you make will not be credited toward satisfying any deductible under your health insurance plan. If you wish to revoke this election and resume billing your insurance carrier, you must sign & submit the Revocation of Patient Election to Self-Pay for Services form. Rum River Counseling will not submit billing to your insurance carrier for previously completed self-pay visits.​

The Good Faith Estimate is a mandate implemented January 1, 2022 by the Federal Government. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services to prevent "surprise" medical billing and has been applied to all medical providers and facilities. It "forces" medical providers to list fees clearly to clients.

Rum River Counseling has always provided transparency in our billing practices by displaying our fee schedule within our Counseling Policies.

Please know that this form does not change any agreements you have already made with us with regard to self pay. Your review of this form and signature is required so that we can demonstrate our compliance with the mandate.

Thank you!