Please print clearly.
First Name: ________________ MI.: ____ Last Name: _________________
Address: ____________________________________________
City: _________________________ State: _________________ Zip: ________
Referred by:_________________ Physician’s Name:______________________
Home Phone: (______) _______-_____________
Work or Cell Phone: (_______) _______-____________
E-mail: ________________________________
Date of Birth: _________________________
Sex: ________________________ Marital Status:____________
Employment Status or School Grade: ___________________________
Parents’ Names (for children) _________________________________
Patient Illnesses_____________________________________________
Patient Medication:
(if needed, continue on reverse
Brief Reason for Coming in:_____________________________________________________________
_____________________________________________________________________________________
Insurance Company: ____________________________________
Subscriber or Policy Holder: _____________________________________
Policy ID#: ______________________ Soc Sec # of Insured (Value Options and CIGNA)________________
Subscriber's Date of Birth: _____________
Relation of Subscriber to patient: _________________________
(Initial as appropriate)
____I authorize Psychological Health Associates, PA, to release information to my insurance company.
____I authorize the payments of Medical Benefits to Psychological Health Associates, PA.
____I authorize the release of information to my (or child’s) physician
____I have read the Psychologist-Patient Agreement and agree to abide by its terms. I have received and read the HIPAA Notification of Privacy Policies.
Signed____________________________ Date_____________
(Signature of Patient or Parent/ Guardian)