I hereby authorize the release of any information acquired in the course of my treatment to my insurance company.
I hearby authorize payment directly to Cullman Family Counseling for my insurance benefits, if any, otherwise payable to me for services rendered.
I permit a copy of this authorization to be used in place of the original.
I understand that if reimbursement isn’t received from my insurance company within 60 days, I am responsible for payment of services rendered.
Signature: _______________________________________ Date: __________________
For how long?
Number prior marriages