COASTAL COUNSELING PATIENT REGISTRATION FORM

 

______________________________________ Doctor/Therapist___________ ________

__________________________________________________________ Date First Appointment_________Time____

 

PATIENT INFORMATION:

 

First Name___________: _______________________ Last:_______________________

Address :_________________________ Telephone#:_________________

________________ _________________________ Emergency #:________________

City:_____________________ State:_____________________ ___________Zip Code:_ ___________ ______

Birth Date: _____________________________ Sex:__________ Marital Status:________________________

Social Security #:______________________ Primary Care Provider:____________

Who may we thank for this referral?_____________________________________

 

If patient is a minor:

 

Name of Father:____________________ Name of Mother:____________________________

Address: ___________________________ Address:________________________

________________ ______________________________ __________________________________________________

City:_______State:___ZipCode______City:________State:_______ZipCode:_____________________________________________ ______Phone: (H)__________(W)_________ Phone:_ (H)_________(W)___________

 

************************************************************************BILLING INFORMATION (Responsible Party)

 

First Name:______________________________ M._______ Last:_____________________

Address:_________________________________ Telephone:________________________

City:_ _________________________________ State: __________ Zip Code:___________

D.O.B. ___________________________________ Social Security Number #:____________

 

INSURANCE INFORMATION

____

Primary Insurance:__________________________________ Phone Number:_______________

Policy Number:_____________________________________ Group Number:________________

Subscriber Name: __________________ Relationship to Insured:__________________

Employer Name:_______________________________ Telephone Number:____________

Secondary Insurance:__________________________ TelephoneNumber:____________

Policy Number:____________________________________________ Group Number:_______________

Subscriber:_______________________ Relationship to Insured:__________________

 

 

 

 

 

Below is a list of questions to help you verify you insurance benefits and facilitate the billing process. It is necessary that you provide this information prior to your first appointment._ If not complete, we will bill the subscriber.

 

1.     Please verify whether or not you need pre-authorization for mental health. Y, N

2.     If so, what is your authorization number. ________________________________

3.     Number of sessions authorized_____________Date:From_________To________

4.     Maximum sessions or total coverage allowed per year ______________________

5.     Co-Pay Due: Sessions 1 through _____$_____; _____through ______$_________

 

Claims Address (for mental health):_ ________________________________________

 

 

Insurance Phone Number ________________ __________Contact Person ______________

 

________________________________________________________________________________ Thank You