Assignment of Benefits Form

ICC Inc. Media Services Portal: Forms

This form is part of the Client Intake Packet. It was last updated May 17, 2021.

Innovative Counseling & Consulting, Inc.

Assignment of Benefits

Instructions: Please complete this form to authorize Innovative Counseling & Consulting, Inc. to receive payment from the client’s insurance or other remittance provider.

Part I: Client Information

Part II: Primary Subscriber Information

Part III: Authorization & Signature

Innovative Counseling & Consulting, Inc. must have a copy of the insurance card, front and back.
By signing below, I am authorizing payment of insurance benefits to Innovative Counseling & Consulting, Inc. for services described. I am also authorizing the release of any information necessary to process this claim.

By clicking “Submit,” you give us permission to email you.


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