Please fill both pages of this form, as it will be used for billing with your insurance company and notifications. 
* - Indicates mandatory information you need to provide. 
PATIENT INFORMATION:	
*Last Name:                                                       *First Name:                                                    Middle Init:   	
*Patient Date of Birth (MM/DD/YY):                                                                 Sex:  M     F    	
*Street Address:                      	
*City:                                               *State:                              *Zip:                         *Phone:(      )  	
*Patient relationship to Insured:   SELF    Spouse    Child    Other 	
INSURED’S INFORMATION. Enter “SAME” in this section, if Patient is the same person as a main Insured person.	
* INSURED’S  ID# :                                                                             SSN: 
We always recommend providing SSN together with ID# due to the fact that some insurers still utilizing it.	
*Policy Group:                                                    Employer Name:  	
*Insurance Plan Name (*Mental Health Provider):  
*Address for Mental Health Claims Submission, P.O. Box/Street Address:
*City:                                               *State:                              *Zip:                         	
Is there another Health Benefits Plan:          Yes                NO          If Yes, provide information on reverse side 	
*Insured Last Name:                                                    *First Name:                                                Middle Initial:    	
*Date of Birth (MM/DD/YY):                                                                        Sex:  M     F    	
*Street Address:  	
*City:                                                *State:                          *Zip:                         *Phone:(      )  	

Acknowledgment FORM:
I authorize use of' this form on all my insurance submissions and the release of information to my insurance company. 
I understand that I am responsible for the full amount of my bill for services provided.
I authorize direct payment to my service provider and hereby permit a copy of this form to be used in place of an original. 
I am responsible to notify this office on any changes in my insurance coverage.
In the event that your account goes to collection, there will be a 20% collection fee added to your balance. 
There is a 24-hour cancellation policy. 
Cancellations with less than 24 hours notice will incur a charge of $60.00, which will be billed to you, as it is not billable to insurance. 
Office Policy requires 72 hours notice for prescription refills.
*Patient Signature:                                                                           *Date:	

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. 
*Patient Signature:                                                                            *Date:	

Please update your contact information that will be used for appointment notifications/confirmations.

Email address (mandatory):   

Primary Contact Phone:                                              

Phone type (please circle one):      Home          Office           Land Line              Cellular

Secondary contact Phone:           
                        
Phone type (please circle one):      Home          Office           Land Line              Cellular

Can we send a Text SMS message for appointment reminder and confirmation to your cellular phone?
                                                 
                                                                                                     Yes                NO          

What company is your cellular provider? (Please circle one):

    AT&T              VERIZON        T-MOBIL           SPRINT       Metro PCS          Other (please specify):

What is a preferred method to confirm your appointment? (Please circle one)

                 EMAIL                 Text SMS Message                     PHONE CALL	

Please note that you are responsible to notify this office when any of your contact information change (mailing address, phone numbers, email address).

*Pharmacy Name  	
*Street Address:                                                        *City:                                               * Phone: (        )	
*Medications List: