Client Information & Insurance

Client Information

First name

Last name

Date of birth

Contact Information

Phone number

Email address

Address

Primary Insurance

If you are paying privately (self-pay) and not using insurance, you can skip this entire section and the one below it.

Insurance company (other)

Plan name

Member/policy ID

Group number

Policyholder name

Policyholder date of birth

Policyholder relationship to client

Insurance Card

Please provide photos showing the front and back of your insurance card

Insurance card front

Add file

Please upload a file

Insurance card back

Add file

Please upload a file

Secondary Insurance

Do you have secondary insurance?

Yes No

Insurance company (other)

Plan name

Member/policy ID

Group number

Policyholder name

Policyholder date of birth

Policyholder relationship to client

Insurance Card

Please provide photos showing the front and back of your insurance card

Insurance card front

Add file

Please upload a file

Insurance card back

Add file

Please upload a file

Authorization

I authorize the release to the above insurance companies of my medical or other information necessary to process insurance claims. I authorize payment of medical benefits to be made directly to the provider of services.

I authorize the release of information and payment of benefits as described above. I understand that submitting this form with my name constitutes my legal electronic signature.

Date

Your information will be encrypted.