INSURANCE VERIFICATION FORM

  • Previous Mental Health Counseling if any
  • Agreement to Financial Responsibility

    I assume responsibility for all charges rendered for my care. I have received a copy of the office procedures as well as the HIPPA agreement and agree to its conditions. Dr. Debra Dupree reserves the right to add service charges of $4.00 per month on outstanding patient balances. I authorize payment directly to Dr. Debra Dupree of group insurance benefits otherwise payable to me.
  • (type your full name)
  • Copy of the Front and Back of my Health Insurance Card
    Drop files here or
    Accepted file types: jpg, gif, png, pdf.