Stephen Rothenberg, Psy.D.

75 Arlington Street, Suite 500, Boston, MA. 02116
Phone: 617/274-8734 Fax: 617/507-8343 Email: braincoach@gmail.com
Welcome.Please take a few minutes to provide the following information:
INSURANCE AUTHORIZATION AND ASSIGNMENT: I hereby authorize the provider
of service to furnish information to insurance carriers concerning my
condition and treatment I hereby assign to the provider all payments
for medical services rendered to myself or my dependents. I UNDERSTAND
THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE.
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Your signature below indicates that you have received and read the Psychotherapist-Patient agreement in its entirety and agree to its terms. It also serves acknowledgment that you have received the HIPPA notice form described above. If there any portions of the agreement that are unclear, it is your responsibility to ask her therapist for clarification prior to signing this form.
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