New Client Information Form

Therapist's Name *
who you will be seen by
Today's Date

Month Day Year
New Client Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Gender M or F *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Email
Insurance Information
Type of Coverage (select all that apply):

Self Pay (no insurance coverage) Primary Insurance Secondary Insurance
Primary Insurance Carrier
Policy Holder Name

First Name Last Name
Date of Birth

Month Day Year
Relationship to Client
self, spouse, dependent
Contract #
including any letters
Group #
Insurance Phone # (Back of Card)
Please enter a valid phone number.
Secondary Insurance Carrier
Policy Holder Name

First Name Last Name
Date of Birth

Month Day Year
Relationship to Client
self, spouse, dependent
Contract #
including any letters
Group #
Insurance Phone # (Back of Card)
Please enter a valid phone number.
I give my authorization to release medical records to assist in the processing of my insurance claims. I also authorize Michigan Medical Billing Services, LLC to receive the information needed regarding my account to bill my insurance and for payments of my claims to be mailed directly to my provider and/or providers office named above for providing my services. I understand that I am completely responsible for any charges incurred and that billing my insurance does not guarantee payment of the claim(s). If the provider of service does not receive payment in a timely fashion, I understand that I may receive a bill for services rendered. I have also received a copy of the HIPAA policies and practices from my provider.
Signature *

Clear
**Please include a picture of your insurance card(s), font and back
Load Pictures of Insurance Cards here:

Cancel of
Should be Empty:

New Client Information

Insurance Information