Assignment of Benefits Please sign and date the Assignment of Benefits and Release of Information statements below. Your signature allows Veronica D. Rasmussen MSW LICSW, of Sound Christian Counseling Inc., to bill your insurance carrier for all services provided to you. Assignment of BenefitsI authorize the payment of medical health benefits to Sound Christian Counseling Inc., and I understand that I am personally responsible for any deductible, co-pays, or noncovered charges.Print Name SignatureDate MM slash DD slash YYYY Driver’s License or IDMax. file size: 128 MB.Insurance Card front and backMax. file size: 128 MB.RELEASE OF INFORMATION I authorize the release of any medical information necessary to process this claim and request that payment for all services be made payable to Sound Christian Counseling Inc. at the address listed below.Print Name SignatureDate MM slash DD slash YYYY Sound Christian Counseling, Inc, 4800 S. 188th St. Suite 260, SeaTac, WA 98188For Office Use Only:Checklist: Copy Front and Back of Insurance Card Two Signatures Required Above Claim Form All Information Requested Answered Properly Provider SignatureDate MM slash DD slash YYYY Authorization For TreatmentName By signing this agreement I authorize the staff of Sound Christian Counseling to evaluate, treat or provide consultation to the person named above. I will be involved in the development of my treatment plan and have been informed about the kinds of therapy being offered to me (i.e. individual, group, family, prayer ministry etc.).My therapist has informed me, of the fees charged and the methods of payment.I understand that information about my care is confidential and will be handled in a confidential manner. I also understand that in some instances Sound Christian Counseling, Inc. is authorized by law to release information without an authorization, for example, if your therapist thinks you are a danger to yourself or others, or; has reason to suspect a child, elderly person, or developmentally delayed person is being abused, or the information is court ordered or permitted by lawI understand the above and have asked any questions. I acknowledge receipt of a copy of this authorization. Client SignatureDate MM slash DD slash YYYY Parent/Guardian SignatureDate MM slash DD slash YYYY Therapist SignatureDate MM slash DD slash YYYY CAPTCHA
