I authorize At Your Pace Counseling, LLC to release information to the insurance companies provided on this form in order to submit insurance claims on my behalf. This authorization extends to the extent necessary to obtain payment for the services provided to me, and includes authorization to release information about mental health, substance use, or HIV diagnoses as required. In consideration of the services provided to me, I assign all benefits to At Your Pace Counseling, LLC if accepted, and authorize my insurance companies, Medicare, or other third-party payers to make payments directly to At Your Pace Counseling, LLC and its affiliates. I understand that I remain responsible for all amounts due by me, including (but not limited to) copays, coinsurance, deductible amounts, and all services not covered by my insurance plan (including those for which I fail to obtain prior authorization), and mutually agreed-upon services or fees that are deemed not medically necessary. I understand that I must send a clear photograph (or scan and send) a picture of the front of my insurance card to office@aypc.email, so that it can be placed in my electronic file before I can schedule my first therapy session. I understand that fees related to court appearances, subpoenas, depositions, attorney meetings, etc. will not be billed through insurance and I am responsible for their payment. I also attest that I’ve read, understood, and agree to At Your Pace Counseling, LLC’s policy regarding court and associated fees.