I authorize the provider to submit claims on my behalf and that payment of insurance benefits for VA Community Care mental health counseling/therapy be made on my behalf to the provider Debbie Harris, LPC for any mental health services provided to me by that organization. This agreement confirms the start of my mental health therapy based on the dates authorized on the VA referral and it’s affiliation with TriWest.

I authorize the release of any and all medical or other information necessary to determine these benefits or the benefits payable for related services to TriWest Healthcare Alliance. I understand that a copy of this authorization will be sent to TriWest Healthcare Alliance. The original will be kept on file by the organization.

I understand that I am not financially responsible to the organization for any charges not covered by the health care benefits since mental health services are rendered under VA Community Care. I am not responsible for the bill or balance of the bill as determined by TriWest Healthcare Alliance if the submitted claims or any part of them are denied for payment.

I understand that by signing this form, I am not accepting financial responsibility as explained above for any payments for services received.