Client Insurance Form

Client Insurance Form

OREGON ONLY
Name

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referring Physician or Individual

First NameLast Name
If you want our sessions billed to your insurance company, please read and fill out the following information: Your insurance may or may not pay me. You will be responsible for payment in full regardless of what your insurance company pays. Your insurance company will ask for a diagnosis and sometimes a treatment plan. I will consult with you on either or both. Please sign this release of information so my billing company can send documentation to your insurance company and to acknowledge that you understand that you are responsible for payment in full.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
INSURANCE COMPANY (include complete address & phone #)
Insurance Name
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Policy Number
Insured Name

First NameLast Name
Insured Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured ID Number
I hereby authorize insurance benefits for medical services to be paid directly to the
provider listed in the billing.
Insured Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Insurance Form

INSURANCE COMPANY (include complete address & phone #)