P & A Child Intake form

P & A Child Intake form

Please be sure to fill out the entire form and press the "Submit" button at the end
Child’s Name (listed on insurance)
Child is called
Date of Birth

MonthDayYear
Date
Social Security Number
Gender
Street Address
City
State
Zip
Phone #1
(used for appt reminders)
Name listed under?
Phone #2
Name listed under?
Email Address
example@example.com
Person Responsible for Payment
Street Address
City
State
Zip
Phone #1
Phone #2
Phone #3
Social Security Number
Employed By
Insurance
PRIMARY Policy
Subscriber’s Name
Birth date of Subscriber
Relation to patient
Employer
Contract Number
SECONDARY Policy
Subscriber’s Name
Birth date of Subscriber
Relation to patient
Employer
Contract Number
PLEASE LET US KNOW TODAY if you are using your EAP for your initial visits.

YesNo
If Yes, name & auth no.

This child lives with
Relationship to Child
If applicable, child is in legal custody of
If so:

Full?Joint?
Father’s name
Mother’s name
Stepfather’s name
Stepmother’s name
I understand that, as a courtesy to me, Pitts & Associates files my insurance. I understand that Pitts & Associates is NOT responsible for keeping up with my insurance company’s deductible, co-pays and/or the number of visits authorized by my Insurance. I also understand that my insurance company is NOT responsible for my bill, but that I am. If my insurance company does not pay in a timely manner, I will pay the bill in full.
Signature: (e-signature) Patient or Responsible Party

Clear
Date

MonthDayYear
Date
I (We), the undersigned, hereby agree to pay all amounts and charges for services rendered by Pitts & Associates, Inc., no later than 30 days of the rendering of said services unless other specific arrangements are made. In the event of default of payment of said services, I (we) waive as to this debt all rights of exemptions under the constitution and laws of the State of Alabama, or of any other state, as to personal property, and agree to pay all costs of collection or securing or attempting to collect or secure said indebtedness, including a reasonable attorney’s fee.

I ALSO UNDERSTAND THAT UNLESS A CANCELLATION OF AN APPOINTMENT IS MADE 24 HOURS IN ADVANCE OF SAID APPOINTMENT, I WILL BE SUBJECT TO CHARGE FOR THE TIME RESERVED
Signature: (e-signature) Patient or Responsible Party

Clear
Date

MonthDayYear
Date
I authorize the release of any medical information necessary to process this claim and request payment to Pitts & Associates, Inc.
Signature: (e-signature) Patient or Responsible Party

Clear
Date

MonthDayYear
Date

Insurance Worksheet

For your convenience, insurance claims are filed by our office staff following your visit. You may be responsible for a co pay or deductible amount at the time of service.

If you plan to use insurance to help pay for services at Pitts & Associates, you will need to verify your coverage for

mental health services before the first session. We have included a form at the end of this document to assist you in this

process. Contact information for your insurance provider is usually located on the reverse side of your insurance card.

The following insurance companies are accepted by one or more of our clinicians. Please contact your insurance provider to verify your coverage.

Blue Cross Blue Shield of Alabama	Out of State Blue Cross Blue Shield
Federal Blue Cross Blue Shield	Medicare
United Behavioral Health	Tricare
VIVA Health	Aetna
Behavioral Health Systems	Cigna

Questions to ask your insurance company before your first visit with us:

What are my outpatient mental health benefits?
What is my yearly deductible?
Has it been met yet?
What is the renewal date for my benefits?
What is my co-pay once the deductible has been met?
Is authorization required? If so, what is my authorization number?
How many visits does this authorize?
What needs to be done to request additional visits? (Clinician send in treatment plan?)
Where? fax number or address
Where are insurance claims mailed?
PLEASE UNDERSTAND. Your insurance will NOT cover any charges for missed appointments or late cancellations (less than 24 hours advance notice).
Should be Empty:

P & A Child Intake form

Insurance

Insurance Worksheet