{"content":[{"text":"ASSIGNMENT OF BENEFITS AND CONSENT FOR SERVICES","bbox":{"left":0.174902,"top":0.091611,"width":0.6558229999999999,"height":0.019463999999999995}},{"text":"This form is to serve notice that Leslie Rawlings LCSW-R, CASAC, MTS \n fee schedules are based upon client's needs and may differ in rates based on such \n needs. \n I understand that I am responsible for any fees for services rendered \n based on the pre-agreed rate which will be stated below. I understand that \n Leslie Rawlings LCSW-R, CASAC, MTS does not participate with any in- \n network insurances. Fees may be submitted through out-of-network by \n clients but Leslie Rawlings LCSW-R, CASAC, MTS does not guarantee \n insurance payments. Please note each specific medical insurance has its own \n policies and guidelines. \n I authorize the release of any medical information necessary to process my \n claims. I also agree to pay a finance charge of 1.5% per month on any balance due \n over 90 days, as well as all collection, court costs, attorney fees and interest fees \n accrued with the collection of this account.” \n It is office policy that,Leslie Rawlings LCSW-R, CASAC, MTS, \n withhold the release of medical records to patients and/or lawyers until \n outstanding bills/balances are paid in full. \n If you have any questions concerning the information outlined above, please \n don’t hesitate to ask the front desk for clarification.","bbox":{"left":0.117647,"top":0.132217,"width":0.7627919999999999,"height":0.385524}},{"text":"Fee Schedule Rates:","bbox":{"left":0.117647,"top":0.538883,"width":0.195612,"height":0.019464000000000037}},{"text":"Consultation:","bbox":{"left":0.35866,"top":0.538883,"width":0.133459,"height":0.019464000000000037}},{"text":"$__________","bbox":{"left":0.503566,"top":0.538883,"width":0.12575800000000004,"height":0.019464000000000037}},{"text":"Subsequent Sessions: $__________","bbox":{"left":0.35866,"top":0.57949,"width":0.33806899999999995,"height":0.019464000000000037}},{"text":"By my signature I/We indicate that I/We have read and understand this \n assignment of benefits, office policies, and give consent for services to be rendered \n by Leslie Rawlings LCSW-R, CASAC, MTS. I am aware by signing below that I \n voluntarily agree to its terms.","bbox":{"left":0.117647,"top":0.620096,"width":0.761179,"height":0.08007000000000009}},{"text":"Name of Client:_____________________________________________________","bbox":{"left":0.117647,"top":0.747065,"width":0.7535540000000001,"height":0.019464000000000037}},{"text":"Signature of Client: _____________________________","bbox":{"left":0.117647,"top":0.787671,"width":0.5181039999999999,"height":0.019464000000000037}},{"text":"Date: ______________","bbox":{"left":0.652671,"top":0.787671,"width":0.21543400000000001,"height":0.019464000000000037}},{"text":"Parent/Guardian of Client:_________________________ Date: ______________ \n (If under 18)","bbox":{"left":0.117647,"top":0.828277,"width":0.7497879999999999,"height":0.039767}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}