UBH Consent FormMichelle Bovenizer2021-09-14T08:31:07-05:00 UBH Consent Form for Non-Credentialed Providers Client Name(Required) First Last Client Date of Birth(Required) Month Day Year Therapist Name(Required) Clinical Supervisor I have been informed that the therapist providing services for me is not credentialed by my insurance provider and is currently under the supervision of a UBH credentialed provider. However, I further understand that this will be reimbursed as an in-network service.Patient or Parent/Guardian Signature(Required)Type your name here. Your Email(Required) NameThis field is for validation purposes and should be left unchanged.
