While Rogue River Counseling does not accept or work in conjunction with insurance carriers, one of the services we provide is to submit your Insurance claims electronically once a month. Many insurance carriers may reimburse you for part of your out-of-network expenses. If you would like us to submit your claims electronically please fill out and submit this form. When you arrive to your first appointment, provide us with a copy of your insurance card and driver’s license.

Be sure to read and accept the Disclosure Statement at the end of this form.

  • Hidden
    MM slash DD slash YYYY
  • Fill out this section if the client is not main insurance policy holder:

  • MM slash DD slash YYYY
  • Drop files here or
    Accepted file types: jpg, gif, pdf, png, Max. file size: 10 MB, Max. files: 2.
    • Disclosure Statement

    • I give permission for Rogue River Counseling (RRC) to submit to the above insurance company all information required and pertaining to my counseling sessions. This is a service provided by RRC allowing the client to submit for partial reimbursement for their services, depending on the client’s insurer and plan. RRC is in no ways responsible for the client’s reimbursement, Insurance Provider’s requests/demands regarding to fee changes, or in engaging the insurance company with any disputes for the claim. I understand that RRC with share my insurance information, DOB, and diagnosis with the insurance company. However the details of our counseling session will certainly remain confidential.

    • Type your name below to sign this document.
    • This field is for validation purposes and should be left unchanged.