Registration Form | 4psych.com

Today's Date

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Social Security Number

Responsible Person if other than patient

Learned about our services from

Professional
Friend or Relative
Internet

Please provide name of Professional or Friend/Relative

Date of Birth*

Are you planning on using health insurance?

Yes
No
Not sure

If you are planning on using insurance have you checked to see if we are on your plan?

Yes, I have verified you are in my network
Yes, you are not in my network.
No, but I intend to before my first visit.

We will need social security number to process your insurance*

You may provide insurance information later and submit your past visits at that time.

Do you have a secondary insurance policy?

Yes
No
Not sure

Insurance Information

Name of Insurance Company

Insured's Plan ID number

Plan Group #

Insurance Verification Phone Number or Customer Service

Address for Claims Submission

Insured's Name

Patient's relationship to insured

Self
Spouse
Child

Insured's Date of Birth **/**/****

Insured's Employer

Name of Secondary Insurance Company

Secondary Plan ID number

Secondary Insurance Plan Group #

Secondary Insurance Verification Phone Number or Customer Service

Secondary Insurance Address for Claims Submission

Fee Agreement

Fees*

I agree to the stated fees

Our fees are $195 per hour of testing or psychotherapy. Therapy sessions are for 45-50 minutes. Psychological testing services include actual time administering tests, test scoring, research, and report writing. Claims will be filed electronically on a weekly basis if using insurance.

Cancellations and Missed Appointments*

I agree to the cancellation and missed appointment policy.

Responsibility for the fee is incurred when an appointment is made and the time is reserved for you. To avoid being charged, please call to cancel appointment 24 hours in advance. Late cancellations and missed appointments will be billed at regular fee. Insurance cannot be billed for missed appointments.

Insurance Non-payment*

I agree to the insurance nonpayment policy

There are times when insurance companies will not reimburse as expected. However, it is understood by accepting the services offered you are willing to pay regardless of your company’s ultimate coverage. You agree to be responsible for checking and verifying your exact insurance coverage. If claims are not paid by your insurance company in 90 days, you agree to be responsible for payment. You always have the option of contacting your insurance company to inquire about claims filed on your behalf.

Assignment of Insurance Benefits*

I agree to have claims filed on my behalf.

HCFA insurance form box 12 and 13. I authorize the release of any medical information necessary to process my insurance claims. I also request payment of medical benefits to my doctor for services rendered.

Credit Card Authorization*

I agree to pre-authorized credit card billing.

We require credit card information to be on file as a guarantee against unpaid balances. You may also use your credit card on file for recurring co-pays. By presenting the credit card information you authorize psychological associates to charge your account for any balance is not paid for by insurance and for any late cancellations or missed appointments.

Note regarding credit card information: When you provide credit card information online your information is entered into Square credit card processing service. All of your information is stored on the secure Square site. No information is kept in our office.

Patient Name

Name as on Card*

Zip code associated with the card*

Account #*

Expiration Date*

Security Code*

Consent to fee agreement and office policies*

I agree to the terms of the fee agreement and office policies

I have read the above the agreement, have asked any questions that I may have, and agree to the terms described above. I have reviewed a copy of the HIPPA privacy notice and a copy of office policy and procedures. I consent to receive services from Psychological Associates (If a parent, I consent for my minor child to receive services. )

Upload File(s)

Drop files here or

Max. file size: 64 MB.

Use this field to upload any files you would like to accompany your registration. For example, any prior medical records you would like us to review, medication list, referral note, or any other file. If you are able, a picture of your insurance card, front and back would be helpful.