ASSIGNMENT OF BENEFITS AND RELEASE FORM

Karin Elise Weber, LCSW, PLLC

1936 William Street, Suite 4 and 5

Fredericksburg, VA, 22401

Phone: (540) 455-4714

Fax: (540) 371-5715
ASSIGNMENT OF BENEFITS AND RELEASE FORM
DEMOGRAPHIC INFORMATION
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Home Phone
Please enter home phone number
Cell Phone
Please enter cell phone number
Work Phone
Please enter work phone number (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Client SSN*
Enter in any format
Referral Source
Contact Person*

First NameLast Name
Contact Person - Relationship to Client*
Emergency Contact Phone Number
Please enter a valid phone number.
INSURANCE & BENEFIT INFORMATION

Please fill out all fields to your best knowledge. An image of the insurance card is not required.
Optional - Add Image of Insurance Card FRONT

Cancelof
Optional - Add Image of Insurance Card BACK

Cancelof
Insurance Company
Provider Services Phone #
This number is typically found on the back of your insurance card.
Insurance ID #
Group #
Subscriber Name

First NameLast Name
Subscriber DOB
Client Relationship to Subscriber
Ex: Self, Child, Spouse, etc.
Subscriber Employer
Subscriber SSN
Policy Effective Date

MonthDayYear
Co-pay/Co-Insurance
Deductible (Amount met?)
# Visits Allowed
Cancellation and Overdue Billing

Please provide at least 24 hour for cancellation to avoid a late cancellation/missed appointment fee. A missed appointment fee of $50 will be charged to the credit card on file. Reschedule missed appointments within one week of original appointment to avoid this fee.

Billed charges that are unpaid by insurance after 60 days will be charged to the credit card on file. You will be refunded for any overpayment once insurance payments are received.

Certification and Authorization

I certify that the above information is correct. I authorize the release of any medical information necessary to process this claim. I request that payments be made directly to Karin Elise Weber, LCSW, PLLC on my behalf. Therefore my signature will be on file to file with my insurance company.
Signature of Client (or Parent/Legal Guardian if client is a minor)*

Clear
Signature Date

MonthDayYear
Please verify item.*
Should be Empty:

ASSIGNMENT OF BENEFITS AND RELEASE FORM

DEMOGRAPHIC INFORMATION

INSURANCE & BENEFIT INFORMATION