Patient Registration and Billing Form

First Name

Last Name

Permanent Street Address

Apt #

City

Zip

Social Security #

Home (Tel)

Cell Phone

DOB

Gender

Do you prefer to text?

Yes

Your relationship to client

Self

Parent/Legal Guardian

Legal Representative

Other

Emergency Contact

Relationship

Tel. (Days)

Tel. (Eves)

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

Birthday (If client is not the primary insured)

Primary Insured Address

Secondary Insured:

PLEASE UPLOAD PHOTO OF PRIMARY INSURANCE CARD FRONT AND BACK

Insurance Card Front

Insurance Card Back

Birthday (If client is not the secondary insured)

Secondary Insured Address

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.

Your Signature

Date

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.

Clients name

Cardholder's name

Cardholder's billing address

Apt #

City

Zip

Charge card number

Experation date

Security code (back of card)

Cardholder's signature

Date

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