OFFICE USE ONLY Therapist ________________ Iowa       Nebraska        (circle one) Single (  ) Married (  ) Divorced (  ) Military – Active (  ) Dependent (  )

                                                SPENCE COUNSELING CENTER, P.C.

Today’s Date:___________                                                                                        

                                                            CLIENT INFORMATION

 

Patient Full Name: ________________________________________________________                        

 

Address: _______________________________________  City: ____________________ 

 

State: ______     Zip: _______________  Guarantor SS#: ___________________  Client DOB: __________________

 

Gender: Male (   )  Female (   )  Race: ________________  Age: _____ County of Residence ____________________

 

Home Phone: ____________________  Work Phone: ______________________

 

Cell Phone: ______________  Employer: _____________________   E-mail: ________________________________

 

Emergency Contact Name & Phone Number: __________________________________________________________

           

FAMILY INFORMATION

 

Name                                       Date of Birth                             Gender                         Relationship

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

 

PRIMARY INSURANCE COVERAGE INFORMATION

 

Primary Insurance: _________________________________________________________________________________

Insurance Address/Phone: ___________________________________________________________________________

Insured Name: _________________ M (  ) F (  )   Insured DOB: ____________  Relationship: ____________________

Insurance Type:  Medicaid (  ) BC/BS (  ) United Healthcare (  ) Midlands Choice (  ) Other (  ) ___________________

Policy#: _________________ Grp#: _____________ Deductible?: $_________ Deductible Met?: Yes  or  No

Co-pay?: Y/N. If yes, Amt: $ _____ Do you have Out-of-Network benefits? ______ Is an Authorization required? _____

 

SECONDARY INSURANCE COVERAGE INFORMATION

 

Secondary Insurance: ______________________________________________________________________________

Insurance Address/Phone: __________________________________________________________________________

Insured Name: ________________ M (  ) F (  )   Insured DOB: ____________  Relationship: ____________________

Insurance Type:  Medicaid (  ) BC/BS (  ) United Healthcare (  ) Midlands Choice ( ) Other ( ) ____________________

Policy#: _________________ Grp#: _____________ Deductible?: $_________ Deductible Met?: _________________

Co-pay?: Y/N. If yes, Amt: $ ______ Do you have Out-of-Network benefits? ____ Is an Authorization required? _____

 

1) I hereby give consent to Spence Counseling Center for myself and/or my dependents in the evaluation and treatment  

     regarding my therapy that may be advisable or necessary in their opinion.

2) I authorize any holder of medical information on myself and/or my dependents to release said information needed to  

    determine benefits payable for medical services.  I further authorize payments for services furnished to myself and/or

    my dependents be made payable to Spence Counseling Center.

3) I understand and agree that I must notify Spence Counseling Center within 24 hours to cancel or change an

     appointment  for myself and/or dependents.  If not, I will be billed and agree to pay the full session fee. 

4) I agree to notify Spence Counseling Center as soon as possible if my name, address, phone, or insurance information

    changes.  If insurance coverage changes, I will bring in the card(s) as soon as possible.

5) Having insurance coverage does not guarantee payable benefits.  I understand that I am responsible and agree

     to pay for any deductibles, co-pays, or any amounts not covered by my insurance.

6) Any past due fees of balances over $200.00 and/or later than 60 days will accrue a monthly 2% late charge to

     my account.

7) This consent shall hold valid for this and all future visits unless revoked in writing.  My signature demonstrates that   

     I have read, understand, and agree to the above.

 

________________________________   ___________________________   ____________________________

                        Signature                                              Print Name                                            Date Signed