Common Contracts
1 similar Financial Agreement contracts
Diane Forse, MSW, LCSW Licensed Clinical Social Worker License #0904009534Financial Agreement • September 21st, 2020
In accordance with the services that will be provided by Diane Forse, LCSW, I hereby agree and authorize my insurance company to pay Diane Forse, LCSW in full for services rendered in accordance with my medical benefits as agreed to in my insurance policy. I hereby authorize Diane Forse, LCSW to release to my insurance company any information necessary for seeking reimbursement for the services listed below.
