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 SupervisorI 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) PhoneThis field is for validation purposes and should be left unchanged.
