• 1117 S Milwaukee Ave., Libertyville, IL 60048
  • 495 N Route 21, Gurnee, IL 60031
  • 1232 American Way, Libertyville, IL 60048
Lake County
Care Collective
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Authorization Consent & Release of Information

Lake County Care Collective · Complete the form below, select your providers, then print or save as PDF.
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Instructions
Please print out a copy of the Release of Information form, fill out your name and information, select all LCCC providers who are treating you, select the most appropriate box for the information allowed to be discussed, and sign. Once completed, please email a copy to each provider you’ve selected.
Section 1 — Client Information
Section 2 — Authorize Release Between Providers

I hereby authorize the release of information between the providers I select below. Check all providers you authorize to discuss your care.

✓ 0 providers selected
Section 3 — Scope of Release

Or specify below: e.g. information about risk, how many sessions I attended, general prognosis, diagnosis, treatment recommendations, etc.

Or describe your own purpose below:

Section 4 — Expiration & Signature
I understand that I can revoke this request and authorization at any time. I also understand that this authorization expires one year from today's date unless otherwise indicated below.
Sign on the printed copy
  • Libertyville & Gurnee, IL
  • info@lakecountycarecollective.com
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Kim Echtle · Billing Services

Billing & Credentialing Menu

Credentialing
Insurance
Fee
BCBS
$250
Aetna
$250
Cigna (Evernorth)
$250
Tricare
$250
Optum (UBH, UMR)
$250
Medicare
$500
Medicaid
$1,000
Monthly Billing & Bookkeeping

Normal billing companies charge 7–10% of billable income. For example, if you charge $10K/month (avg. $100/client, 25 clients/week), you would pay a 3rd-party billing company $1,000/month. Compare that to our flat rates below.

Client Volume
Monthly Rate
1–10 clients
$200 / month
10–20 clients
$300 / month
20–30 clients
$400 / month
30–40 clients
$500 / month
Account Setup
Full Account Setup
$250 one-time fee

Includes: therapy appointment setup (insurance setup, credit card setup, consent forms, client setup), QuickBooks account setup, and Availity & CAQH update.

Extra Services for Your Clients
Horse Therapy Facility
$50 per session

Due at time of session · Provided at our partner farm

L&K Acres

4319 McCauley Rd, Woodstock, IL 60050

Friday & Saturday only (for now)

Liability waivers must be signed for every new client coming to the farm.

Ready to get started?

Reach out to Kim directly — she'll take it from there.

Email Kim