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Patient Registration and Billing Form

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Marital Status
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Your relationship to client

PLEASE UPLOAD PHOTO OF DRIVERS LICENSE FRONT AND BACK

License Front
License Back

Insurance Information

Primary Insured:

PLEASE UPLOAD PHOTO OF INSURANCE CARD FRONT AND BACK

Insurance Card Front
Insurance Card Back

Secondary Insured:

PLEASE UPLOAD PHOTO OF PRIMARY INSURANCE CARD FRONT AND BACK

Insurance Card Front
Insurance Card Back

I hereby authorize Kristen Marie Scott, LCPC, to furnish information concerning my diagnosis and treatments to my insurance carrier(s) and request my insurance carrier(s) to direct payment to Kristen Marie Scott, LCPC.

Credit Card Payments

I authorize Kristen Marie Scott, LCPC, to keep my signature on file and charge my

(VISA, MASTERCARD, DISCOVER) card account.

Charges may be posted for: (1) amounts stated in the signed Payment Contract for Services with the clinic, (2) all balances not paid by insurance or other third-party payers after 60 days, and (3) fees for appointments canceled with less than 24 hour's notice (a charge of $50).

I undsertsand this form is valid for two years unless I cancel the authorization through written notice to the clinic.

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