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- I authorize the release of information to my insurance company(s).
- I understand that I am responsible for full amount of my bill for services provided.
- I authorize direct payment to my service provider.
- I authorize use of this form on all of my insurance submissions.
- I hereby permit a copy of this form to be used in place of an original.
- It understand that it is my responsibility to pay any deductible amount, co-pay, co-insurance amount or any other balance not paid by my insurance the day and time service is provided.
- There will be a $35.00 service charge on all returned checks.
- In the event that your account goes to collections, there will be a 20% collection fee added to your balance.
- I understand that there is a charge of $80.00 for cancellations with less than 24-hours notice or no-show appointments. Cancellations must be made during regular office hours, between 9:00 AM and 5:00 PM Monday through Friday.
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I understand that all services rendered by Calvary Counseling Center are final and non-refundable.
Thank you for filling out the Insured/Responsible Party Information form.
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