Registration Form New Patient Information Today's Date Month Day Year Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail 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* Month Day Year 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 InformationName of Insurance Company Insured's Plan ID number Plan Group # Insurance Verification Phone Number or Customer ServiceAddress 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 ServiceSecondary Insurance Address for Claims Submission Fee AgreementFees* I agree to the stated feesOur 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 policyThere 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 policiesI 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 Select files 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.