Billing-Insurance Information Form

The MCPST Billing-Information Form gives you information about MCPST clinic policies and procedures; fees for intake and ongoing sessions; private pay fee agreement; assignment of benefits for insurance; and asks for client and insurance information.

You can download a printable copy of the MCPST Billing-Insurance Information Form.

Please visit our MCPST Forms page for information about how to use this form if you are a new client.

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Midwest Center for Psychotherapy & Sex Therapy · 6300 University Avenue, Suite 125 · Middleton, WI 53562 · (P) 608-237-8000 · (F) 608-237-8005