Cathy Weeg Billing Agreement

Cathy Weeg, LPC

Counseling and Therapy Services

Billing Agreement

I understand and agree that it is my responsibility to check with my insurance carrier regarding coverage of counseling and what types of providers are covered under my plan.

Client Information

Client Name

First Name: M.I. Last Name:

Client Address

Street Address: City: State: Zip:

Home Phone:

Business Phone:

Cell Phone:

Email:

Social Security Number:

Date of Birth:

Other Responsible Party

If someone other than the client is responsible for payments, please fill in the information below:

Name (Other Responsible Party)

First Name: M.I. Last Name:

Address (Other Responsible Party)

Street Address: City: State: Zip:

Home Phone:

Business Phone:

Cell Phone:

Email:

Social Security Number:

Date of Birth:

Primary Insurance

Insured's ID#:

Insured Policy, Group or FECA#:

Insurance Company:

Primary Insured

If someone other than the client is the primary insured for this policy, please fill in the information below:

Name (Primary Insured)

First Name: M.I. Last Name:

Address (Primary Insured)

Street Address: City: State: Zip:

Home Phone:

Business Phone:

Cell Phone:

Email:

Social Security Number:

Date of Birth:

Relationship to Client:

Do you have Supplemental Insurance

Yes

Supplemental Insurance

Insured's ID#

Insured Policy, Group, or FECA#

Insurance Company

Primary Insured

If someone other than the client is the primary insured for this policy, please fill in the information below:

Name (Supplemental Insured):

First Last

Address (Supplemental Insured):

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone:

Business Phone:

Cell Phone:

Email:

Social Security Number:

Date of Birth:

Relationship to Client:

Assignment of Benefits

I authorize payment by my insurance company to be paid directly to Cathy Weeg, LPC and Jennifer Danhauser, LPC for services rendered. I understand that I am financially responsible to for charges applied to the insurance deductible and for all charges limited by the insurance carrier. I authorize Cathy Weeg, LPC and Jennifer Danhauser, LPC to give copies of any records when needed for payment by my insurance carrier and/or its affiliates.

By typing your name below, you authorize payment by the insurance company listed in this document.

Consent(Required)

I agree to the privacy policy.

Date of SIgnature:(Required)

Signature of Client or Legally Responsible Person:(Required)

First Name: M.I. Last Name:

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