ADULT
Financial Responsibility
THERAPIST
DX CODE
INSURANCE
CO-PAY
(971) 34
5
-
5777 fax (503)990
-
6927
AUTHORIZATION #
DATE
/
Month
/
Day
Year
Date
CLIENTS NAME
DATE OF BIRTH
/
Month
/
Day
Year
Date
AGE
PHONE
E-mail
example@example.com
GENDER:
MALE
GENDER:
FEMALE
FEMALE
Address
ADDRESS
Street Address Line 2
CITY
State / Province
ZIP
CITY:
REFERRED BY
REASON FOR SERVICES
MARITAL STATUS:
NEVER MARRIED
MARITAL STATUS:
MARRIED
SEPARATED
DIVORCED
WIDOWED
VETERAN STATUS:
YES
NO
OTHER THERAPIST/DOCTORS YOU HAVE SEEN
PHONE
PHONE
PHONE
INSURANCE INFORMATION
PRIMARY INSURANCE
POLICY HOLDER NAME
POLICY HOLDER’S BIRTH DATE.
/
Month
/
Day
Year
Date
Address
ADDRESS
Street Address Line 2
CITY
STATE
ZIP
PHONE
ID#
GROUP #
SECONDARY INSURANCE
POLICY HOLDER NAME
POLICY HOLDER’S BIRTH DATE.
/
Month
/
Day
Year
Date
Address
ADDRESS
Street Address Line 2
CITY
STATE
ZIP
PHONE
ID#
GROUP #
How would you like to receive your billing statement (Choose one)
:
Mail
How would you like to receive your billing statement (Choose one):
Email
SIGNATURE
DATE
/
Month
/
Day
Year
Date
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