Lighthouse Family Center



LIGHTHOUSE FAMILY CENTER LTDREGISTRATION FORMCLIENT INFORMATIONDATE:__________________Client Name___________________________________Soc Sec #____________________________Address_______________________________________ Phone #_____________________________City___________________________ State_________ Zip______________ County________________Date of Birth ____________________ Age_______ Sex______ Marital Status____________________Occupation: _________________________________________________Employer____________________________________________________________________________Address_____________________________________________________________________________Race/Ethnicity: ○Asian ○Black/African American ○Native American/American Indian ○Caucasian ○Hispanic ○Middle Eastern GUARANTOR INFORMATION (Person responsible for charges not covered by insurance)___Same as above ORName__________________________________________ Soc Sec #___________________________Address________________________________________ Phone #____________________________________________________________________________ Date of Birth ________________________INSURANCE INFORMATIONPrimaryName of Insurance Company____________________________________________________________Policy Number__________________________________ Group Number________________________Name of Policy Holder____________________________ Birthdate____________________________Relationship to Client_____________________________ Effective Date________________________Address________________________________________ Phone #____________________________________________________________________________SecondaryName of Insurance Company____________________________________________________________Name of Policy Holder____________________________ Birthdate____________________________Policy Number__________________________________ Group Number________________________Relationship to Client_____________________________ Effective Date________________________~ over ~ AUTHORIZATION FOR RELEASE OF INFORMATIONI hereby authorize Lighthouse Family Center LTD to release such information in connection to my treatment to the above-named insurance company(ies) for the purpose of processing insurance claims.ASSIGNMENT OF INSURANCE BENEFITSI hereby authorize payment of the benefits otherwise payable to me by the designated insurance company(ies) directly to Lighthouse Family Center LTD. Payments shall not exceed regular charges.***PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED***Signed__________________________________________________ Date_______________________Client / Parent / Guardian / Legal RepresentativeSigned__________________________________________________ Date_______________________Witness_________________________________________________ Date_______________________REMINDER CALLSIn order to provide our clients with appointment reminder calls, Lighthouse Family Center Ltd requires written permission from the client / parent / guardian.I would like an appointment reminder callI would like a text messagePhone Number: ____________________________________________Signature: _______________________________________________ ................
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