Insurance Information Update and Consent to Treatment (Pg 3 Only)

Patient Name

First NameMiddle InitialLast Name

Patient Date of Birth

Date

Will Bay Area Psychological Consultants be filing insurance on your behalf?

No Insurance/Do Not File to InsuranceFile to Insurance

Primary Insurance Carrier

Primary Insurance Effective Date

Date

Primary Insurance Policy Number/Member ID

Primary Insurance Group Number

Primary Policy Holder Name

First NameMiddle InitialLast Name

Primary Insurance Policy Holder's Date of Birth

Date

Primary Insurance Policy Holder's Relationship to patient:

SelfSpouseParentOther

Has policy coverage for Bay Area Psychological Consultants been verified with the insurance carrier by patient?

YesNo

Secondary Insurance Carrier

Secondary Insurance Effective Date

Date

Secondary Insurance Policy Number/Member ID

Secondary Insurance Group Number

Secondary Insurance Policy Holder Name

First NameMiddle InitialLast Name

Secondary Insurance Policy Holder's Date of Birth

Date

Secondary Insurance Policy Holder'sRelationship to patient:

SelfSpouseParentOther

Has policy coverage for Bay Area Psychological Consultants been verified with the insurance carrier by patient?

YesNo

Please be informed that Bay Area Psychological Consultants files insurance as a courtesy and it is in no way a guarantee that your insurance company will pay for services rendered. All claims are subject to the written conditions of your policy. You, as the patient, are ultimately responsible for the account and any follow-up contact needed with your insurance carrier. Your signature is required in order to file insurance and receive services.

I agree to assign all insurance benefits not to exceed total charge to my psychotherapist at Bay Area Psychological Consultants. I agree for any information to be released to insurance companies and/or sponsoring agencies for the purpose of verifying outpatient and/or inpatient diagnosis, treatment and other data. I hereby agree to be responsible for the cost of any non-covered services as notified by a periodic statement and my explanation of benefits.

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered at the time of service.

I, the undersigned party, do hereby give my consent to of Bay Area Psychological Consultants in the capacity of psychotherapist for treatment of First Name Last Name.

Signature of Patient or Parent/Guardian

DATE

Date

Name of Individual signing form if not Patient

First NameLast Name

Relationship to Patient

Parent/Guardian/Power of Attorney

Please take or upload a photo of Primary Insurance ID Card

Please take or upload a photo of Secondary Insurance ID Card

Please Take or Upload a Photo of a State Issued ID Card of Patient/Parent or Guardian