Licensed Independent Mental Health Practitioner


Please take a few minutes to review the following policies and procedures. Let me know if you have any questions.

Appointments


Clients may meet with therapist by appointment only. If there is a need to cance l an appointment, please give 24 hour notice, or you may be charged for the missed appointment.

Payment


Please contact your insurance company to be aware of benefits, deductibles &/or co - payments or co - insurance amounts. These payments are due at the time of each appointment unless other arrangements have been made. Claims will be filed by a third party billing service if the following authorizations are signed. If for any reason your insurance does not cover your therapy, you are responsible for the full amount.

Authorizations


I hereby authorize release of information by Dena Crosby Counseling, LLC to my insurance company and also authorize my insurance benefits to be paid dir ectly to Dena Crosby Counseling, LLC for services rendered. I agree I am financially responsible for all charges not covered by my insurance. Further, I grant release of all information in my file to Methodist Health Partners, a third party organization wh ich contract with certain insurance companies to provide for quality assurance in providers such as Dena Crosby Counseling, LLC, for the purpose of record keeping audits. Further, I grant the release of information to third parties involved in the billing and collection of fees for services rendered by Dena Crosby Counseling, LLC sufficient to perform that function.

I understand the above policies and I hereby authorize counseling services by Dena Crosby Counseling, LLC.