Intake Forms for PFPA

Thank you for choosing Powers Ferry Psychological Associates (PFPA)

At PFPA, we believe that healing begins with feeling seen, heard, and supported.

Todays Date:

Patient's Fiull Name

NO NICKNAMES

Date of Birth

Age

Last four of SSN

Phone: Home

Phone : Cell/Mobile

Email address (if none, type the word None)

If patient is a minor: Parent(s)/Guardian(s) Email

Mailing Address

City

State

Zip Code

If patient is a minor: Parent/Guardian Name(s)

Financial Responsible Party Information

Responsible Party Name

No Nicknames

Date of Birth

Last four of SSN

Same As Above

Check box if mailing address and No. are the same as the patient's.

Mailing Address

City

State

Zip Code

Phone No: Home

Phone No: Cell/Mobile

INSURANCE INFORMATION

Disclaimer Regarding Insurance Benefits and Payment: Please be advised that any quote of benefits and/or prior authorization received is not a guarantee of payment or a confirmation of eligibility. All claims are subject to the terms, conditions, limitations, and exclusions outlined in the members’ insurance policy in effect at the time services are rendered. Verification of benefits is for informational purposes only and does not ensure coverage or payment by the insurance carrier. Ensure that you reach out to your insurance carrier as well for further information. PFPA will make commercially reasonable efforts to submit insurance claims and pursue payment from insurers and clients on behalf of the provider. However, PFPA does not guarantee reimbursement, nor does it assume financial responsibility for the collection of such payments.

Yes

Will you be SELF-PAY with PFPA? If so, please check the YES box to the left and enter 'N/A' in the fields marked as mandatory below.

Please send in the front and back of the insurance card to patientforms@pfpaga.com or the provider. If it does not apply, please enter 'N/A' in the fields where it is mandatory.

Policyholder’s Name

Policyholder’s DOB

Policyholder’s SSN

Policyholder’s Employer Name

Insurance Name

Insurance ID No.

Insurance Group No.

Insurance Provider No.

Policyholder’s Name

Policyholder’s DOB

Policyholder’s SSN

Insurance Name

Secondary Insurance Clamis Adderss

Insurance Phone No.

Provider Department

Insurance ID No.

Insurance Group No.

Authorization Information/Employee Assistance Program (EAP)

Authorization Number /EAP

If it does not apply, please enter 'N/A' in the fields where it is mandatory.

EAP Company Name

Who are we to submit EAP's to (Cigna, Aetna, United, etc)

EAP Authorization No.(Auth)

This field MUST be Completed if using EAP's

EAP's Insurance Phone

EAP's End Date

EAP's Start Date

NO. Of Allowed Sessions

If an extension is needed for the EAP auth, please get in touch with your employer or the insurance company.

Notes

Your information will be encrypted.