Responsible Party Info

If you have any trouble submitting this form, please download and print the pdf and fax it to us at (703) 530-9805. Download

PERSONAL INFORMATION
EMPLOYER INFORMATION
INSURANCE INFORMATION
EAP CLIENTS ONLY





  1. I authorize the release of information to my insurance company(s).
  2. I understand that I am responsible for full amount of my bill for services provided.
  3. I authorize direct payment to my service provider.
  4. I authorize use of this form on all of my insurance submissions.
  5. I hereby permit a copy of this form to be used in place of an original.
  6.  It understand that it is my responsibility to pay any deductible amount, co-pay, co-insurance amount or any other balance not paid by my insurance the day and time service is provided.
  7. In the event that your account goes to collections, there will be a 20% collection fee added to your balance.
  8. I understand that there is a charge of $50.00 for cancellations with less than 24-hours notice or no-show appointments.

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Office Hours

 

Monday – Thursday 9 AM – 7 PM

Friday By Appointment Only

Saturdays  8 AM – 3 PM

 

*Times are subject to change.  Please contact our office with your scheduling questions.

 

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