Billing and/or Insurance Information

Billing and/or Insurance Information
Client Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Social Security Number*
Marital Status*
Employer*
Primary Physician*
Referred by*
Is Client under 18 years of age?*

YesNo
Responsible Party/Parent or Guardian Information

This section MUST be completed client is under 18 years of age. This person will receive any bills acrued at LCFC.
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Social Security Number*
Employer*
EAP/CAP/AAP INFO
Employer*
Employee*
Relationship to Client*
Primary Insurance Information
Insurance Company*
Contract Number*
Group Number*
Employer*
Policy Holder*

First NameMiddle NameLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Date
Relationship to Client*
Do you have secondary insurance?*

YesNo
Secondary Insurance Information
Contract Number*
Group Number*
Group Number*
Employer*
Policy Holder*

First NameMiddle NameLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Date
Relationship to Client*
Emergency Contact Information
Same as Guardian Above*

YesNo
Relationship*
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
I grant permission for LCFC to send me information (eg., newsletters, client info, etc.) via email.*

YesNo
Date*

MonthDayYear
Date
Signature
Should be Empty:

Billing and/or Insurance Information

Client Information

Responsible Party/Parent or Guardian Information

EAP/CAP/AAP INFO

Primary Insurance Information

Secondary Insurance Information

Emergency Contact Information