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.

*This form can be filled out on your computer if you prefer. Be sure to download and save the form to your computer first or you will lose what you typed. Click the down arrow to download the form and open it with your computer’s PDF viewer (such as Adobe Reader) – NOT your internet browser. Fill out the form, save the file and print it to sign and return to us.

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