AUTHORIZATION TO BILL INSURANCE
I, _________________________(client name), DOB_____________, hereby authorize Lauren Penn, LCSW, to bill my insurance company/employee assistance program ____________________ for my treatment. My Subscriber/Member ID is ____________________________. My Group Number (if applicable) is __________________. The phone number to verify mental health benefits is __________________________. The primary subscriber (if not myself) is ___________________________, DOB ___________, whose address (if different from mine) is _______________ _______________________________________________________ and who is employed by ______________________________________.
I understand that my diagnosis will be provided to my insurer. I understand that the insurance company may request additional clinical information regarding my treatment progress in order to authorize sessions and/or payment, and I authorize Lauren Penn, LCSW, to provide such information as necessary.
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Client or Guardian’s Signature Date
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