Printer Friendly Signature On File 
Insurance Claims
Northern Psychology Resources, LLC accepts most insurance and will bill on the behalf
of our clients as a courtesy. This in no way alleviates the financial responsibility of the
individual accepting services. We do not accept, or bill, Aetna Insurance or Medicare. If
you have coverage with either of these you will be expected to pay NPR directly and
submit information to your insurance company for reimbursement yourself. We will be
happy to provide any information from our office that you may need.
Financial Policy
I, the undersigned, understand that I am financially responsible for all services rendered
at Northern Psychology Resources, LLC for myself and my dependants. I request that
NPR file my insurance claims, when applicable, on my behalf. I understand that my
insurance company may not cover all costs related to my services and I am responsible, at
the time of service, for any co-pays, deductibles, and non covered expenses. I agree to
pay my portion at each visit unless PRIOR arrangements have been made. If payment
has not been received from my insurance company within 45 days I understand that the
balance of the account becomes my responsibility and due immediately. There will be a
$35.00 NSF charge for all returned checks. If a check is returned and payment is not
secured immediately the account will be sent to collections. Payment may be made with
CASH, Check, or Visa/MasterCard Credit Cards.
Past Due Accounts
All accounts that have a balance after 45 days will be assessed a finance charge of 1.5%
per month. If the account is not paid in full within 120 days, or acceptable arrangements
have not been made in writing with our office, the account will be sent to a collection
agency and no further services will be rendered until the account is paid in full. Any
services requested after such time will be on a cash-only basis.
Signature on File
I authorize the release of any necessary information, including any treatment records or
summaries, to my insurance company or a consulting professional in order to secure
payment on my behalf. The information released to my insurance company is solely for
the purpose of obtaining financial reimbursement directly to Northern Psychology
Resources, LLC; and Dr. Jacqueline Bock, PhD. I request and authorize my insurance
company to pay Northern Psychology Resources, LLC directly for all services rendered.
I authorize the use of the signature on this page on all insurance submissions. I also
authorize the release of any information necessary to consult with other professionals
regarding current and continuing treatment, and in the event of a referral to another
provider of service.
See our printer friendly form for authorizations and signature line.
Printer Friendly Signature On File
Insurance Claims
Northern Psychology Resources, LLC accepts most insurance and will bill on the behalf
of our clients as a courtesy. This in no way alleviates the financial responsibility of the
individual accepting services. We do not accept, or bill, Aetna Insurance or Medicare. If
you have coverage with either of these you will be expected to pay NPR directly and
submit information to your insurance company for reimbursement yourself. We will be
happy to provide any information from our office that you may need.
Financial Policy
I, the undersigned, understand that I am financially responsible for all services rendered
at Northern Psychology Resources, LLC for myself and my dependants. I request that
NPR file my insurance claims, when applicable, on my behalf. I understand that my
insurance company may not cover all costs related to my services and I am responsible, at
the time of service, for any co-pays, deductibles, and non covered expenses. I agree to
pay my portion at each visit unless PRIOR arrangements have been made. If payment
has not been received from my insurance company within 45 days I understand that the
balance of the account becomes my responsibility and due immediately. There will be a
$35.00 NSF charge for all returned checks. If a check is returned and payment is not
secured immediately the account will be sent to collections. Payment may be made with
CASH, Check, or Visa/MasterCard Credit Cards.
Past Due Accounts
All accounts that have a balance after 45 days will be assessed a finance charge of 1.5%
per month. If the account is not paid in full within 120 days, or acceptable arrangements
have not been made in writing with our office, the account will be sent to a collection
agency and no further services will be rendered until the account is paid in full. Any
services requested after such time will be on a cash-only basis.
Signature on File
I authorize the release of any necessary information, including any treatment records or
summaries, to my insurance company or a consulting professional in order to secure
payment on my behalf. The information released to my insurance company is solely for
the purpose of obtaining financial reimbursement directly to Northern Psychology
Resources, LLC; and Dr. Jacqueline Bock, PhD. I request and authorize my insurance
company to pay Northern Psychology Resources, LLC directly for all services rendered.
I authorize the use of the signature on this page on all insurance submissions. I also
authorize the release of any information necessary to consult with other professionals
regarding current and continuing treatment, and in the event of a referral to another
provider of service.
See our printer friendly form for authorizations and signature line.