I hereby authorize Dean Lierle, LICSW and Splinter Billing Service to release any information acquired in the course of my evaluation and treatment to my insurance company as may be required for reimbursement. I understand that Dean Lierle and Splinter Billing Service will be processing my insurance claims only as a convenience to me. I hereby authorize my insurance company to make payment directly to the provider for services rendered. I understand that I am financially responsible for the charges not paid by my insurance for any reason, i.e.: no authorization obtained, deductible, non-covered service or not a covered provider. If my insurance company pays on any service that I have already made payment, I will be re-imbursed. I understand that the responsible party will receive the billing and that in the case of co-responsibility, only one party will be billed. I also understand that I am responsible for knowing and following insurance procedures which affect approval for payment.