Patient Registration

Patient Registration Form

Kester Counseling, PLLC - P. O. Box 504 - Fowlerville MI - 48836 - 248.210.6012
Patient Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender
Insurance Information
Primary Insurance Co
Policy No
Group No
Primary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Subscriber's Relationship to Patient
Secondary Insurance Co
Policy No
Group No
Secondary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Subscriber's Relationship to Patient
Insurer Information
Name of Insurer
Name of Insurance Rep

First NameLast Name
Rep Phone Number
Format: (000) 000-0000.
Referral Contact Name

First NameLast Name
Referral Phone Number
Format: (000) 000-0000.
Emergency Contact:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In order to submit a claim for payment to us for services covered under your policy, we must have authorization to release medical information to our billing company and your insurance company.

I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to me to the doctor or group indicated on the claim.
Signature and Date

Relationship (if other than patient) ___________________
Should be Empty:

Patient Registration Form

Patient Information

Insurance Information

Insurer Information