REGISTRATION FORM Please complete the Client Information Form below. It will need to be signed at the time of your first appointment.
IF YOU WILL BE USING INSURANCE TO HELP PAY FOR SERVICES, PLEASE COMPLETE THE FOLLOWING: II - Primary Insurance - If Applicable Insurance Company Name Policy Holder Relationship to Client Date of Birth Social Security #: ID # Group # Under Employer's Health Plan? Yes No Employer Address Phone # III - Assignment and Release I, the undersigned certify that I (or my dependent) have insurance coverage with the above mentioned and assign directly to all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the therapist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Client's Signature ______________________________________ Date Responsible Party Signature ______________________________ Date IV - Submission By submitting this form via email, you agree that the information above is correct. We will require your signature on a hard copy at the time of your first appointment.
