Responsible Party Insurance Information

If you have any trouble submitting this form, please download and print the pdf and fax it to us at (703) 530-9805. Download

PERSONAL INFORMATION
EMPLOYER INFORMATION
INSURANCE INFORMATION
EAP CLIENTS ONLY





  1. I authorize the release of information to my insurance company(s).
     
  2. I understand that I am responsible for full amount of my bill for services provided.
     
  3. I authorize direct payment to my service provider.
     
  4. I authorize use of this form on all of my insurance submissions.
     
  5. I hereby permit a copy of this form to be used in place of an original.
     
  6. 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.
     
  7. There will be a $35.00 service charge on all returned checks.
     
  8. In the event that your account goes to collections, there will be a 20% collection fee added to your balance.
     
  9. I understand that there is a charge of $65.00 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.
  10. I understand that all services rendered by Calvary Counseling Center are final and non-refundable.