By signing the form below you agree to the following terms.
Assignment of Insurance Benefits: I hereby authorize the above insurance company to pay
directly to Megan Knowles, LLC D/B/A Expressions Therapy on behalf of the above client. All benefits
due under the policy by reason of services rendered therein by said patients. Irrevocable assignment and
transfer shall be for the recovery on my insurance policy but shall not be construed to be an obligation of
Megan Knowles, LLC D/B/A Expressions Therapy to pursue any such right of recovery. A copy of this
assignment shall be considered as effective and valid as the original.
Release of Medical Record and Information: I hereby consent to disclosure of any such and all
records of information concerning the treatment of the said patient maintained by Megan Knowles, LLC
D/B/A Expressions Therapy for the purpose of insurance claims, or other claims for medical benefits and
for the exchange of information to the referring physician, psychologist, therapist, or other referral source
if appropriate. I have read and understand the above policies/rights and agree to them.