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By using this form below, you understand that your submission may not be a secure and confidential form of communication. If you wish to assure your confidentiality, rather than filling out and submitting this form, you can print and FAX the PDF form you received to: 802-727-4634. The client attests that she/he/they: a) does not have insurance coverage, or b) has insurance coverage, but chooses not to use it, and understands that in doing so s/he is waiving any right to reimbursement, or c) has insurance coverage, but understands that the provider’s services are not covered by the plan. Please fill all fields below to indicate your agreement:
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