Spectrumbehavioralhealthny.com-Patient Demographics/Insurance Information

SPECTRUM BEHAVIORAL HEALTH

New In-take Fax: 845-485-8780

Poughkeepsie Fax: 845-452-7546 / Fishkill Fax: 845-897-3376 / Kingston Fax: 845-331-1479
Patient Demographics/Insurance Information
Patient Demographics
Patient Name (as it appears on your insurance card):*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone*
Work Phone

Area CodePhone Number
Email Address*
example@example.com
Patient Date of Birth*

MonthDayYear
Patient Social Security Number*
Driver's License Number*
Employer Name*

First NameLast Name
Employer Address*
Occupation and Title*
Primary Care Physician Name*

First NameLast Name
Phone Number

Area CodePhone Number
Guarantor Information
(only if the patient is under 18 years of Age)
Guarantor Name

First NameLast Name
Is Mailing Address Same? (choose one)

YesNo
If NO: Mailing Address
Is Patient a Full Time Student ? (choose one)

YesNo
Insurance Information

*Insurance plan must be the correct plan for billing mental health / substance abuse services. Please contact your insurance to verify where mental health / substance abuse claims are sent and if authorization is required.
Primary Insurance Plan Name*
Member ID*
Group #*
Claims Mailing address*
Insurance Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Subscriber Social Security Number*
Insurance Effective Date:*

MonthDayYear
*Secondary Insurance Plan Name

First NameLast Name
Member ID
Group #
Claims Mailing address
Insurance Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Subscriber Social Security Number
Insurance Effective Date

MonthDayYear
Assignment of Benefits

I authorize payment of medical benefits to Spectrum Behavioral Management, Spectrum Psychiatry, PC. and/or Spectrum Psychology and Social Work, PLLC. for services performed. I also understand that non-payment by my insurance, in some circumstances, may result in patient or Guarantor responsibility of charges incurred.
Click field below and use the mouse or your finger to sign:*

Clear
Release of Information

I authorize the release of any medical or other information necessary to process claims to my insurance. I understand that my mental health practitioner may notify my primary care physician of any medications I have been prescribed. I will also inform my primary care physician about my mental health issues and treatments. It is important for my primary care physician to know my medications to prevent potential drug interactions and duplicate prescriptions. **For substance abuse patients: I understand that this disclosure is bound by Title 42 of the Federal Regulations governing the confidentiality of the alcohol and drug abuse patient's records and re-disclosure of this information to another party other than designated by the patient is forbidden without additional authorization.
Click field below and use the mouse or your finger to sign:*

Clear
Date*

MonthDayYear
Should be Empty: