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Patient Info Form 2013

This document contains a patient intake form for Dr. Terry F. Perkins' psychology practice. It requests information such as the patient's name, address, phone number, date of birth, employer, insurance details, and emergency contact. The patient or guardian must sign agreeing to terms such as authorizing the release of information and accepting financial responsibility for any balance.

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terryperkinsphd
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151 views

Patient Info Form 2013

This document contains a patient intake form for Dr. Terry F. Perkins' psychology practice. It requests information such as the patient's name, address, phone number, date of birth, employer, insurance details, and emergency contact. The patient or guardian must sign agreeing to terms such as authorizing the release of information and accepting financial responsibility for any balance.

Uploaded by

terryperkinsphd
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Terry F. Perkins, Ph.D.

License PSY5764 123 Hodencamp Road Suite 106 Thousand Oaks, CA 91360 805.499.2304 Todays date:

PATIENT INFORMATION
Patients last name: Is this your legal name? Yes No Street address: P.O. box: Occupation: City: Employer: State: First: If not, what is your legal name? Middle: Cell Phone ( ) Birth date: / ( / Home phone no.: ) ZIP Code: Employer phone no.: ( Chose office because/Referred to office by (please check one box): Family Friend Close to home/work Other family members seen here: Dr. Other ) Insurance Plan Hospital Age: Sex: M F

Social Security Number

INSURANCE INFORMATION
Person responsible for bill: Is this person a patient here? Occupation: Employer: Birth date: / Yes / No Employer address: Employer phone no.: ( Is this patient covered by insurance? Please indicate primary insurance: Subscribers name: Subscribers ID. no.: Birth date: / Patients relationship to subscriber: Name of secondary insurance (if applicable): Patients relationship to subscriber: Self Spouse Subscribers name: / Child Other Group no.: Policy no.: Group no.: Policy no.: Copayment: $ Yes No Authorization No. ) Address (if different): Home phone no.: ( )

Self

Spouse

Child

Other

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize Terry F. Perkins, Ph.D. or insurance company to release any information required to process my claims. Patient/Guardian signature Date

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