Release for Insurance

  • All clients using health insurance please sign below:

    I hereby grant authorization to Carmen Gehrke with Longwood Therapy, LLC., to release any Protected Health Information (except Psychotherapy Notes) to my insurance company as necessary for billing, to receive authorization for services, or to process my claim for payment of services. I authorize my insurance company to send payment directly Carmen Gehrke with Longwood Therapy, LLC for all services provided. I agree that a photocopy of this authorization shall be as valid as the original.