Confidential Intake Form

CONFIDENTIAL INTAKE FORM
PERSONAL INFORMATION
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Gender*
SSN*
E-mail*
example@example.com
Address*

Street Address / Unit #

Apt/Unit #

CityState

Zip Code
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Work Ext.
Preferred Contact Method (for rescheduling purposes)*

Call Cell PhoneCall HomeCall WorkEmail
Primary Care Physician*
Full Name of PCP (enter "none" if applicable)
PCP Office Phone
Ext.
Emergency Contact*
Full Name of an Emergency Contact
Phone*
Best number to reach Emergency Contact
Relationship to Applicant*
RESPONSIBLE PARTY

Complete if Patient is under 18 or if someone other than Patient is responsible for payment.
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Gender
Address

Street Address / Unit #

Apt/Unit #

CityState

Zip Code
E-mail
example@example.com
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Relationship to Patient
Secondary Responsible Party

AUTHORIZATIONS
AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize the use of disclosure of my individually identifiable health insurance information necessary to process insurance claims. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
Signature*

Clear
DATE*

MonthDayYear
Date
AUTHORIZATION FOR ASSIGNMENT OF BENEFITS FOR INSURANCE

I authorize payment of medical benefits to my provider for services performed.
Signature*

Clear
DATE*

MonthDayYear
Date
FINANCIAL POLICY

Appointment cancelled with less than 24 hour notice will be charged to me at the full fee per hour. I am responsible for the entire balance of services performed regardless of whether there is insurance coverage. Secondary insurance will be billed as a courtesy.

I understand and agree to the above stated financial policy.
Signature*

Clear
DATE*

MonthDayYear
Date
Should be Empty:

CONFIDENTIAL INTAKE FORM