I do hereby give full permission and authorize A Plus Counseling to bill my insurance company for services rendered by A Plus Counseling. I also agree to have any checks or payment made by such insurance company to be payable and deliverable to:

A Plus Counseling
123 East Ave C, Ste B
Heavener, OK 74937

I understand that I am responsible for understanding information about my health insurance policy and providing such information to A Plus Counseling, for correct billing. I am also responsible to notify A Plus Counseling in the case of change of my health insurance status, inclusive benefits, and any information I receive relating to care I have or will receive in this office.

I understand that A Plus Counseling will be providing services and billing my health insurance for those services at various times during the course of my care at this office. I understand that ultimately I am responsible for all payments relating to any and all charges relating to treatment and services that I have received at A Plus Counseling during my care. I also understand that my insurance company and related policy plan may offer benefits for services provided at A Plus Counseling, but that such benefits do not necessarily guarantee payment for those services.

I understand that the policy of A Plus Counseling requires payment in full for all services rendered at the time of visit, unless other financial arrangements have been made. If my account is not paid within 90 days of the date of service and no other financial arrangements have been made, I will be responsible for all legal fees, collection agency fees, and any other expenses incurred in collecting my account.