I hereby authorize Horizon Family and Community Services (facility) and their employees to contact my insurance carrier in order to determine eligibility for medical services. I understand that my insurance will be billed for services rendered by the staff providing treatment. I agree that if my insurance carrier issues a check in my name for reimbursement for services, I will within five days of receipt of this check make payment in the amount of said check to the facility.
The following also applies to the use of my insurance to cover the cost of services rendered: Authorization To Release Medical Information For Billing: I hereby authorize the release of any information regarding services by the Therapist/Facility to process insurance claims and allow a electronic photocopy of my signature to file insurance claims.

Assignment Of Insurance Benefit: I hereby authorize irrevocably assignment of payment for my benefits due me for the services rendered by the facility made directly to the therapist and/or the facility.

Financial Responsibility: I understand that I am financially responsible for all charges whether or not paid by the insurance.