I hereby authorize the provider(s) from Northridge to famish information to my insurance carrier(s) concerning my or my dependents illness and treatment.

I hereby assign the providers from Northridge all payments for behavioral health services rendered to myself or my dependent. I understand that I am responsible for any amount not covered by insurance.

I understand payment in full or co-payment is expected at the time of service for office visits unless other arrangements have been made. Northridge is responsible for providing documentation for me to submit to my insurance carder for reimbursement.

I understand co-payments and deductible payments for certain insurance companies are accepted in lieu of complete payment at the time of my visit. I understand if my insurance company fails to pay for any service rendered to my dependents or to me, l am financially responsible for payment.