New Client Information Form

New Client Information

*** For new client information and benefit estimate requests***
Therapist's Name*
who you will be seen by
Group Name (Please type NA if not applicable):*
Practice Name
Today's Date

MonthDayYear
Benefit Estimate Request*
By Selecting Yes we will email you a benefit estimate.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender on file with insurance (M or F):*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Email
Insurance Information
Type of Coverage (select all that apply):

Self Pay (no insurance coverage)Primary InsuranceSecondary Insurance
Primary Insurance Carrier
Effective Date of Insurance (if known):

MonthDayYear
Date
Policy Holder Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to Client
self, spouse, dependent
Contract #
including any letters
Group #
Insurance Phone # (Back of Card)
Please enter a valid phone number.
Secondary Insurance Carrier
Effective Date of Insurance (if known):

MonthDayYear
Date
Policy Holder Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to Client
self, spouse, dependent
Contract #
including any letters
Group #
Insurance Phone # (Back of Card)
Please enter a valid phone number.
I give my authorization to release medical records to assist in the processing of my insurance claims. I also authorize Michigan Medical Billing Services, LLC to receive the information needed regarding my account to bill my insurance and for payments of my claims to be mailed directly to my provider and/or providers office named above for providing my services. I understand that I am completely responsible for any charges incurred and that billing my insurance does not guarantee payment of the claim(s). If the provider of service does not receive payment in a timely fashion, I understand that I may receive a bill for services rendered. I have also received a copy of the HIPAA policies and practices from my provider.

If the form is signed by the Provider or Providers Office's Staff they are confirming that the client has signed forms indicating the above information and they have that information on file in their office.
Full Name of Person Submitting Form:
**Please include a picture of your insurance card(s), font and back
Load Pictures of Insurance Cards here:

Cancelof
Provider Use Only: Diagnosis Code(s)
if you are not the provider, please leave this box blank
Should be Empty:

New Client Information

Insurance Information