UBH Consent Form for Non-Credentialed Providers

Client Name(Required)
Client Date of Birth(Required)
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.
Type your name here.
This field is for validation purposes and should be left unchanged.
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