Patient Registration Form

Patient's Name:
Age:
Birth Date:
Address 1:
Address 2:
City:
State:
Zip:
Social Security #:
Drivers License:
Occupation:

 
Please indicate your gender.
Male  Female  
 
Patient Privacy Information
 
May we say who we are in case we call your home?
Yes  No  
 
May we say who we are if we phone your work?
Yes  No  
 
Have you received psychological treatment before?
Yes  No  
 
 
Contact Information

Home Phone:
Work Phone:
Cell Phone:
E-mail Address:
Fax Number:

 
 
Emergency Contact

Person to contact:
Relationship:
Phone Number:
Address 1:
Address 2:
City:
State:
Zip Code:

 
Responsible Party (If not patient)

Responsible party:
Address 1:
Address 2:
City:
State:
Zip Code:
Drivers License:
Social Security #:

 
Insurance Information
 
Private  
Private with managed care for mental haelth services  
Medicare  
 

Name of Insured:
Insurance Company:
Identification Number:
Group Number:
Billing Address 1:
Billing Address 2:
City:
State:
Zip Code:

 
Has preauthorization been obtained?
Yes  No  
 
Workers' compensation or Personal Injury: request special form.  
Self Pay: Our services are not covered by Kaiser, Pacificare or HMO companies other than Blue Cross HMO  
 
Secondary Insurance
 

Insured:
Insurance Company
Identification Number:
Insurance City:
State:
Zip Code:
Phone Number:

 
 
Insured or authorized person's signaure:
I authorize payment of medical benefits to therapist for services described.  
 
Digital Signature:
 
Patient's or authorized person's signature
I authorize the release of any medical information necessary to process this claim. I also request payment of government benefits to the third party who accepts assignment  
 
Digital Signature:
 
Date:
 
Instead of this office filing your claim, do you wish a superbill at the end of the month fo your own claim?
Yes  No  
 
Please read the following and sign below
 
I am requesting the service for the designated individual. I agree that all charges accured for srevices renderd to that individual are my responsibility. I understand that servces are not rendered on the assumption that charges will be paid by an insurance company. All co-payments are due at the time services are rendered.   
I agree to give a minimum 24-hour notice for all cancellations of sessions. For sessions cancelled within 24-hours, I understand there may be a fifty-percent session charge. I agree to pay the full session charge fo all missed appointments that are not cancelled prior to the scheduled appointment. I understand these charges are not paid by my insurance and will be my insurance and will be my personal resonsibility. There is a $25 charge for all returned checks  
 
Digital Signature of Responsible Party
 
Date:
 
Others living in the same home with patient
 

Name:
Age:
Relationship:

 

Name:
Age:
Relationship:

 

Name:
Age:
Relationship:

 

Name:
Age:
Relationship:

 

Name:
Age:
Relationship: