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Please take the time to fill out the form below. To save time at your initial visit please bring with you photocopy of your insurance card (front and back) as well as authorizations for treatment from your insurance carrier. Thank you.
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The field marked with (*) are required fields.
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Patient's Full Name (First, Middle Initial, last)
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Patient's social security number
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Patient's Street Address
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Additional address information such as (P.O. Box, Apt.#, etc.)
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City
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State
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Zip Postal Code
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Patient's date of birth
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Patient's Sex (M or F)
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Patient's marital status (S-M-D-W)
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Telephone number(s) - (Please list in order of preference)
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Email Address
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Employer
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Employer's complete address
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Guarantor's Full Name (First, Middle Initial, last) If same as patient, write same and proceed to Primary Insurance Section
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Guarantor's relation to patient (self, spouse, parent)
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Guarantor's street address (if different from above)
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Guarantor's additional address information (if different from above)
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Guarantor's city (if different from above)
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Guarantor's zip code (if different from above)
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Guarantor's telephone number(s) - (Please list in order of preference)
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Guarantor's Employer
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Guarantor's employer's complete address
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Primary Insurance Co.
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Primary Insurance Co. telephone number
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Do you have a deductible (yes or no)
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If yes, how much?
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Claim mailing address
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Group Name
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Group/Plan number
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Insurance ID number
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Secondary insurance (if any)
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Secondary Insurance Co. telephone number
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Deductible amount (if any)
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Claims address information
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Group/Plan information (group numbers, member IDs, etc.)
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I understand that payment is due at the time of service unless other arrangements have been made. I understand that my therapist will be filing my insurance on my behalf. I agree to have the benefits from my insurance assigned to my therapist, Christine Becker. I permit my therapist, Christine Becker to release any information deemed necessary to any insurance company or third party. I agree that I am responsible for full payment of this account. I agree to to be held responsible for all costs associated with collection, including reasonable attorney's fees and court costs.
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Yes
No
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Please do not enter anything in this box. You will be asked to sign the box when we meet. By signing you also agree that you have read "Notice of Privacy Practices" and understand your rights according to HIPAA. Thank you.
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