Demographic information and Office policies

Excel Psychiatric Consultation PC

13243 Executive Park Ter.

Germantown, MD 20874

Tel: 301-820-1715. Fax: 240-597-1060
First Name*
Last Name*
M.I
M/F*
Date of birth:*

MonthDayYear
Date
Address:*
City:*
State:*
Zip code:*
Cellular Phone*
Home Phone
E Mail:*
example@example.com
Name of Emergency Contact*
Emergency Contact’s Telephone*
Relationship to the patient:*
PRIMARY INSURANCE CARRIER
Subscriber’s Name
Subscriber's Date of Birth
Subscriber’s relationship to patient
SECONDARY INSURANCE CARRIER
Subscriber’s Name
Subscriber’s Date of Birth
Subscriber’s relationship to patient
I AGREE THAT I WILL BE RESPONSIBLE FOR NOTIFICATION OF ANY CHANGE IN PERSONAL INFORMATION

I hereby authorize all payments for services rendered to dependents or myself to be paid directly to Excel Psychiatric Consultation, PC. for services provided. I further authorize the release of any necessary information, including medical/ mental health information from this office to my insurance carrier. I understand and agree that I am fully financially responsible for charges not paid by insurance company. I permit a copy of this authorization to be used in place of the original.
Patient /Guardian Name*
Signature*

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Date*

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Excel Psychiatric Consultation PC

13243 Executive Park Ter.

Germantown, MD 20874

Tel: 301-820-1715. Fax: 240-597-1060
Patient /Guardian Name*
Signature*

Clear
Date*

MonthDayYear
Date
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