New Patient Intake Form

REGISTRATION FORM

PATIENT’S NAME:

E-MAIL ADDRESS:

DATE OF 1st VISIT:

REFERRAL:

PRIMARY CARE:

DATE OF BIRTH:

SINGLE MARRIED

ADDRESS:

HOME/CELL PHONE:

WORK PHONE:

OCCUPATION:

NAME OF PRIMARY INSURANCE:

ID NUMBER:

GROUP NUMBER:

SUBSCRIBER’S NAME:

MEDICAID #:

MEDICARE #:

IN CASE OF EMERGENCY, WHO SHOULD BE NOTIFIED?

TELEPHONE/CELL NUMBER:

ASSIGNEMENT OF BENEFITS

Name of Beneficiary:

Health Insurance Claim Number:

I request that payment of authorized

Benefits be made to either me or on my behalf to

for the services furnished to me by the physician. I authorize any holder of medical information to release to the Health Care Financing Administration and its agents any information needed to determine these Benefits or the Benefits payable for related services.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s Signature

Date

CANCELLATION NOTICE

Your appointment time is especially reserved for you.

Please be advised that this office requires a 24-hour notification for ALL cancelled appointments.

A $50 charge will be collected for the missed appointment session.

You are responsible for the time you schedule with this office.

Patient’s Signature

Date

ACKNOWLEDGEMENT OF RECEIPT OF THE PATIENT’S BILL OF RIGHTS

[Patient’s name]

Insurance

Member #

Acknowledge that I have been provided with a copy of the Patient’s Bill of Rights on

Relationship to Patient:

Print Name or Signature of Patient / Responsible Party

Date

ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF HEALTH INFORMATION PRIVACY RIGHTS

acknowledge that I have been provided with a copy of the health Information Privacy Rights [HIPAA]

on this

, have also been advised that the Notice is posted on the U.S. Department of Health and Human Services website at www.hhs.gov/ocr/hipaa or by calling 1-866-627-7748.

Signature:

Client or Authorized Representative

Date

Signature:

Date

[If Applicable]: The reason why a written Acknowledgement of Receipt of the Notice of Privacy was not obtained:

CONSENT FOR PSYCHIATRIC SERVICES

I hereby consent and authorize

Clinician’s / Doctor’s Name

to conduct any tests, examinations and treatments, which in his/her judgment are necessary for the care and treatment of myself or my dependent.

Patient Name:

Relationship to Patient:

Print Name or Signature of Patient / Responsible Party

Date

CONSENT FOR PSYCHOTHERAPY SERVICES

I hereby consent and authorize

Clinician’s / Doctor’s Name

to conduct any tests, examinations and treatments, which in his/her judgment are necessary for the care and treatment of myself or my dependent.

Patient Name:

Relationship to Patient:

Print Name or Signature of Patient / Responsible Party

Date

Member’s Name:

Date

Member ID#:

Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully and check off your response

Member's Name:

Date

Please answer question as best as you can by putting a check in the appropriate box.

Your information will be encrypted.