Client Insurance Form

Client Insurance Form

OREGON ONLY
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
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*

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Date*

MonthDayYear
Date
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.
Group Policy Number*
Insured Name*

First NameLast Name
Insured Date of Birth*

MonthDayYear
Date
Insured ID Number*
I hereby authorize insurance benefits for medical services to be paid directly to the
provider listed in the billing.
Insured Signature*

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Date*

MonthDayYear
Date
Should be Empty:

INSURANCE COMPANY (include complete address & phone #)