verify your co-pay and deductible with your insurance company. I accept cash, credit cards, or checks. Please make your checks payable to Counseling Alaska LLC. In the unlikely case that a check is returned, a $25.00 service fee is assessed . In the event that your insurance company does not pay, you are responsible for fees incurred for services. I reserve the right to use a third party collector if a bill remains unpaid. If your account becomes significantly past due, I reserve the right to refer you to other services that can accommodate your budget. _______ I understand the regulations and have been offered a copy. **Your signature indicates that you have read, understood and agreed to the terms in this document and are willingly entering into therapy with Rebecca Love, LPC. ** Date Signature (Client) ________________________________________________________ ___________ Signature (Parent/Guardian or Witness/Counselor) Date ________________________________________________________ ___________
verify your co-pay and deductible with your insurance company. I accept cash, credit cards, or checks. Please make your checks payable to Counseling Alaska LLC. In the unlikely case that a check is returned, a $25.00 service fee is assessed . In the event that your insurance company does not pay, you are responsible for fees incurred for services. I reserve the right to use a third party collector if a bill remains unpaid. If your account becomes significantly past due, I reserve the right to refer you to other services that can accommodate your budget. _______ I understand the regulations and have been offered a copy. **Your signature indicates that you have read, understood and agreed to the terms in this document and are willingly entering into therapy with Rebecca Love, LPC. ** Signature (Client) Date ________________________________________________________ ___________ Signature (Parent/Guardian or Witness/Counselor) Date ________________________________________________________ ___________
informed_consent_dec_2017.docx