Susan Davis, MA LMHC

Home Contact Insurance Intake 1 Intake 2 Cancellation Form Blog



 


For Provider Use ONLY

Provider Name:                                                                                                            Diagnosis Code:

Referring Provider:                                                                                                     Authorization #:


COMPLETE AND ACCURATE INFORMATION IS REQUIRED

PATIENT

Patient Name_____________________________________________ SS#____________________________

Address_________________________________________________________________________________

City________________________________________________State____________Zip________________

Date of Birth____________________ Male ______ Female_______ Marital Status_________________

Home Phone___________________________ Work Phone ________________________

RESPONSIBLE PARTY Name & address of person responsible for any balance not covered by insurance:

Same as Patient  Other

Name________________________________________

Address_____________________________________ City______________State______Zip_________

Home Phone___________________________ Work Phone ________________________

INSURANCE Include copy of front & back of insurance card

Primary Insurance______________________________________________________________________

Insurance Address________________________________________________Phone____________________

City_______________________________________________State____________Zip___________________

Subscriber #: ______________________________________ Group#: ___________________________

Secondary Insurance______________________________________________________________________

Insurance Address________________________________________________Phone____________________

City_______________________________________________State____________Zip___________________

Subscriber #: ______________________________________ Group#: ___________________________

SUBSCRIBER

Same as Patient  Same as Responsible Party  Other

Subscriber Name___________________________ Date of Birth ____________ SS#__________________

Patient Relationship to subscriber: Self____ Spouse____ Child____ Other (specify)__________________

Employer___________________________________________Phone________________________________

INSURANCE AUTHORIZATION AND ASSIGNMENT: I hereby authorize the Provider of service to furnish information to insurance

carriers concerning my condition and treatment. I hereby assign to the provider all payments for medical services rendered to my

dependents or myself. I UNDERSTAND I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE.

Signature______________________________________________________ Date ____________________