HRA New Insurance Form

Please fill out our electronic form below. Alternatively, you can view / download / print our form for manual submission using the link below.

Client Name*

Date of Birth*

mm/dd/yyyy

Gender*

MaleFemaleOther

Carrier:*

Policy Holder:*

Policy Holder Date of Birth*

mm/dd/yyyy

ID#:*

Group#:*

Have you called your insurance company for authorization?*

YesNoNot Required

Parent/Guardian Name:

Parent’s Status:

Are both parents aware that treatment has been requested?

YesNoNot Sure

I hereby authorize payment of medical benefits through my insurance policy to HRA Psychological Services. I have listed all health plans from which I may receive benefits. I hereby accept responsibility for payment for any services provided to me that are not covered by my insurance.

I agree to pay all copayments, coinsurance, and deductibles at the time services are rendered. I also accept responsibility for any missed appointment/late cancellation fees, NSF check fees, and a $10.00 charge per month on all overdue balances (past 60 days

I hereby authorize HRA Psychological Services to use and/or disclose my health information which specifically identifies me or that can reasonably be used to identify me to carry out my treatment, payment, and health care operations.

I understand that while this consent is voluntary, if I refuse to sign this consent, HRA Psychological Services can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions taken by HRA Psychological Services prior to receipt of my revocation.

I further give authorization to run my credit card if I choose to call and pay for services over the phone.

Click here to view our full financial policies.

Signature of Patient or Patient's Representative*

New Insurance Form

Insurance Information

For Minor Clients Only

Consent for Payment