Mental Health Insurance Billing Services for Therapists ...

 Intake FormDemographic InformationFirst Name: ______________________________________________________Middle Initial: ______________________________________________________Last Name: ______________________________________________________Date of Birth: ______________________________________________________Social Security Number (Optional): _____________________________________Sex: M FMarital Status:______________________________________________________Address: __________________________________________________________City:______________________________________________________________State: __________________________________________________________Zip Code: ________________________________________________________Phone Number: ____________________________________________________Email Address: ____________________________________________________Referring Physician Name (Optional): ____________________________________Referring Physician Phone Number & NPI (Optional) : _______________________Insurance InformationPrimary Insurance Company: __________________________________________Subscriber ID # (including letters): _______________________________________Group Number: ____________________________________________________Secondary Insurance Company: ________________________________________Subscriber ID # (including letters): ______________________________________Group Number: _____________________________________________________Insurance Policyholder Full Name: ______________________________________Insurance Policyholder Date of Birth: ____________________________________Insurance Policyholder Address: _______________________________________Insurance Policyholder Relationship: Self Spouse Child OtherInsurance Policyholder Social Security Number: ____________________________Insurance Policyholder Sex: M F* Note: All information is required.Patient AuthorizationI authorize the release of any medical and insurance information necessary to process any claim. Patient Signature: _____________________________________ Date: __________Guardian Signature (if minor): _____________________________ Date: __________Patient Full Name: ____________________________________________________Managed Care / HMO PatientsI understand that it is my responsibility to obtain a valid referral from my primary care physician, if a referral is required by my insurance plan. I understand that if I do not obtain or have a referral on file that I may be held financially responsible for services received. I further understand that I am responsible for services that are considered non-covered expenses by my insurer.Patient Signature: _____________________________________ Date: __________Guardian Signature (if minor): ____________________________ Date: __________Patient Full Name: _____________________________________________________* Note: All signatures are required.Credit Card On FileCredit Card Full Name: ___________________________________________________________________________Credit Card Number: ___________________________________________________________________________Expiration Date: __________/______________ Security Code (3 Digits for Visa, 4 Digits for AMEX): ____________ ................
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