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

Client Name *

First Name Last Name

Client Date of Birth *

Month Day Year

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

City State / Province

Postal / Zip Code

Email Address

example@example.com

Client SSN *

Enter in any format

Referral Source

Contact Person *

First Name Last Name

Contact Person - Relationship to Client *

Emergency Contact Phone Number

Please enter a valid phone number.

Optional - Add Image of Insurance Card FRONT

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Optional - Add Image of Insurance Card BACK

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Insurance Company

Provider Services Phone #

This number is typically found on the back of your insurance card.

Insurance ID #

Group #

Subscriber Name

First Name Last Name

Subscriber DOB

Client Relationship to Subscriber

Ex: Self, Child, Spouse, etc.

Subscriber Employer

Subscriber SSN

Policy Effective Date

Month Day Year

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

Month Day Year

Please verify item. *

ASSIGNMENT OF BENEFITS AND RELEASE FORM

DEMOGRAPHIC INFORMATION

INSURANCE & BENEFIT INFORMATION