Insurance Verification Form

Date of First Visit
MM
DD
YYYY
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Date of Brith
MM
DD
YYYY
Sex
- Male
- Female
Referred By
Marital Status
Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Previous Mental Health Counseling if any
When
Where
With Whom
Personal Physician
Primary Physician's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Insurance Name
Primary Insurance Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Name of Policy Holder
Relationship
INSURANCE ID#
GROUP ID#
Secondary Insurance Name
Secondary Insurance Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Name of Policy Holder
Relationship
SSN#/ID#
GROUP ID#
Agreement to Financial Responsibility
I assume responsibility for all charges rendered for my care. I have received a copy of the office procedures as well as the HIPPA agreement and agree to its conditions. Dr. Debra Dupree reserves the right to add service charges of $4.00 per month on outstanding patient balances. I authorize payment directly to Dr. Debra Dupree of group insurance benefits otherwise payable to me.
Signature
(type your full name)
Date
MM
DD
YYYY
ATTACHMENT:
Copy of the Front and Back of my Health Insurance Card
Drop files here or

Accepted file types: jpg, gif, png, pdf.

Agreement to Financial Responsibility