Insurance ID # *

Insurance Carrier *

Your Name as it Appears on Your Insurance Card: *

Your Date of Birth *

Relationship to Insured: *

Insured's Name: *

Insured's Date of Birth: *

Full Mailing Address: *

Date You Called Your Insurance Company: *

Total Deductible Amount: *

Deductible Met This Year: *

Copay Amount or Copay %: *

Telehealth Coverage During COVID-19: *

Date COVID-19 Telehealth Coverage Expires (as of today's date): *

Telehealth Coverage Post COVID-19: *

By initialing below, I authorize Louisville Mindfulness Center to release any medical information necessary to my insurance company for me to access my benefits. I understand for me to use my insurance benefits, a diagnosis will need to be assigned to me. *

By initialing below, I understand I am responsible for my copay or when deductible has not been met, the full contracted rate per session, at the time services are rendered. *

By initialing below, I understand that if a deductible is due before insurance will pay benefits, I understand I am responsible to pay each session's contracted insurance rate in full to Louisville Mindfulness Center until that deductible is met. I am also responsible for alerting provider when deductible has been met and co-payment changes. *

By initialing below, I understand services provided may not be covered through my Health Insurance. This may be die to diagnosis or service provided. It is my responsibility to determine if health insurance covers the services provided and will provide reimbursement. *Please inquire specifically about telehealth services during and after the Covid19 pandemic.* *

By initialing below, I understand I am responsible for all fees NOT paid by insurance, for any reason. If a balance occurs on my account, I agree to pay a late fee of $25 per week, from the last service rendered without payment, until my balance is paid in full. *

By typing my full name below, I attest that I am effectively providing my signature, indicating that I understand and agree to the above stated terms. *