Effective date: 2024-11-04
I request to receive audio-only telehealth services from my clinician at Shelterwood Collective, PLLC. I understand that I will be billed at my clinician’s regular billing rate for these services. I authorize Shelterwood Collective to bill me directly for audio-only telehealth services. I also authorize Shelterwood Collective to bill any applicable third party payer for eligible audio-only telehealth services. I also understand that these services may not be eligible for reimbursement under my health insurance benefits and that I have the ultimate responsibility to determine what services my health insurance plan will cover.