James M. Read, Ph.D.
Clinical Psychologist
http://www.jread.com
2304 North Cole Road, Suite B -- Boise, Idaho 83704-7371 -- Telephone (208) 377-0271 -- Facsimile (208) 377-3134
Electronic mail -- jread@jread.com

This form will allow us to bill your insurance company directly and collect that portion
of our fee which your policy specifies is payable under the terms of the policy.

Name of patient:__________________________________________________

Commencing date:________________________________________________

I hereby authorize payment directly to James M. Read, Ph.D., for psychological or
counseling services to the above named patient.

I hereby agree that the psychologist may receipt for any such payment and that his
receipt shall be conclusive acknowledgement by me that I have received benefits
from my insurance carrier in the sum specified in such receipt, and agree that such
payment shall discharge the said insurance carrier of any and all obligations under
the policy to the extent of such payment and for that purpose I expressly authorize
the psychologist to furnish the insurance company with whatever information it
desires concerning said psychological/counseling care.

I understand that I am financially responsible to the psychologist for charges not
covered by this agreement.

Policy Holder's signature: _____________________ Date: __________________

Witness: _______________________________________ Date: _________________

Revised March 24, 2003