- Step 1 of 2First Name *Last Name *Middle InitialHome Address *City *State *Zip Code *Date of Birth *Age *Gender *MaleFemaleTel (Home):Tel (Cell):SSN#: *Empolyer: *Occupation: *Employer Address: *Employer Telephone # (Ext if any)Primary Care Provider Name (PCP): *Phone Number: *NextPrimary Insurance *Subscriber/Member Id# *Group#: *Effective Date: *Subscriber’s Employer: *Occupation: *Relationship to Patient *Subscriber NameSubscriber DOB:Subscriber SS#Subscriber AddressSecondary InsuranceSubscriber/Member Id#Group#: Effective Date: Subscriber’s Employer: Occupation: Relationship to PatientSubscriber NameSubscriber DOB:Subscriber SS# Subscriber AddressEmergency Contact Name:Contact Phone Number:Relationship to Patient:FINANCIAL AGREEMENT: I acknowledge that psychological / psychiatric services will be provided by either both or one of the Providers listed below. *I understand and agree that, I am fully responsible for any balance on my account for any and all professional services rendered, regardless of my insurance status. In the case of any changes to my health status or information provided above, I will notify your office immediately. I am also aware that an independent billing contractor is authorized to bill and collect on their behalf.My signature below also authorizes the release of any and all information necessary to process insurance claims to my insurance company (ies) as well as payments to be made directly to: Dr. Mavis M. Alaimalo, PsyD, Ltd. * Clear Signature" Patient SignatureDate *CommentSubmit
Comments are closed.