New Client Information Form

Therapist's Name *

who you will be seen by

Group Name (Please type NA if not applicable): *

Practice Name

Today's Date

Benefit Estimate Request *

Name *

First Name Last Name

Date of Birth *

Gender on file with insurance (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

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

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

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:

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New Client Information

Insurance Information