Client Information Form (Online Submission) Name * First Name Last Name Date of Birth MM DD YYYY Email * Contact via Email? Is it ok to contact you via email? Yes No Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Home Phone - Leave a message? Is it ok to leave a message on your home phone? Yes No Mobile Phone (###) ### #### Mobile Phone - Leave a message? Is it ok to leave a message on your mobile phone? Yes No Referred by Person responsible for payment Medical Insurance Do you have medical insurance Yes No Insured's Name First Name Last Name Client's Relationship to Insured Insured's Date of Birth MM DD YYYY Employer Insurance Company Plan ID Insurance Company Address Address 1 Address 2 City State/Province Zip/Postal Code Country Additional Insurance Yes No Specify ID # for Additional Insurance Phone for Additional Insurance (###) ### #### Primary Care Physician Primary Care Physician Phone (###) ### #### Emergency Contact Emergency Contact Relationship Emergency Contact Phone (###) ### #### Electronic Signature * Fee & Cancellation Policy A 48- Hour notice is required to cancel or reschedule the weekly session without charge. Client Agreement I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered. I have read all the information on this sheet and certify the information I have provided is true and correct to the best of my knowledge. First Name Last Name Date Signed * By typing your name and date on this electronic form, you are agreeing to the above policy and terms. MM DD YYYY Signed Name * Financial Policy Information • The choice of insurance plan coverage is often complex and benefits vary for everyone. Some individuals may choose not to use insurance or may have a policy/plan that I do not participate with; in those situations, the client is considered “self-pay.” I am currently an In-network provider with Medicare as well as the Horizon PPO and Traditional Plans. • You should be aware that coverage for mental health services is not necessarily the same as for medical services, and that there may be restrictions on which type of mental health services are reimbursable. I recommend that clients inform themselves of all aspects of their insurance policy coverage, including deductible, copayment schedule, authorization/pre-certification requirements, and any service limitations. It is the responsibility of the patient to provide me with their current insurance information at the time of the initial appointment. • Additionally, the client must notify me as soon as possible of any insurance policy changes. Even minor alterations in a policy can change reimbursement substantially. I cannot be held responsible for inaccurate billing if I was not informed of insurance changes. When appropriate, I will be happy to update my billing fees from the time of notice going forward. • Any policies or services outside the scope of the contract or carrier approval are the responsibility of the client at non-contract rates. (For example, Horizon EPO and HMO policies are outside the scope of my Horizon contract.) • Appointments canceled without 24 hour notice will be billed to the client at the full chargeable session fee. Cancellation charges cannot be billed to insurance. • The client should assume that, regardless of their insurance status, they are ultimately responsible for any outstanding account balance for services rendered. Once treatment is terminated, all outstanding bills must be paid within 30 days. Out-of-Network Insurance • If I do not have a contract with a client’s insurance company, the client is responsible for payment at time of service, and for filing the claim with their insurance company. The client is also responsible for resolving problems with insurance coverage claims. In-Network Insurance • If pre-authorization is required, it is up to the client to get the initial authorization or precertification, and be aware of the renewal process. I will do my best to renew current authorizations, provided that I have all accurate insurance coverage information; otherwise, the client will be responsible for the full chargeable session fee. • All terms of a contract will be observed if I have the current policy information at the time of billing. This includes payment limits, billing, copayments and authorization. The contract may place limits on number of sessions and frequency. Client will be responsible for the full cost of the session for such limitations. • Insurance companies may require disclosure of privileged information for treatment authorizations; use of any insurance coverage implies the policy owner’s permission for the release of information. Should this be requested, only the minimum information, as protected by NJ law, will be released. • If you do not inform me of your participation in a plan at the start of treatment or within 30 days of policy changes, non-contract conditions and rates apply. First Name Last Name Financial Terms Agreement Date * MM DD YYYY Thank you for your submission. < BACK TO FORMS PAGE DOWNLOAD-Client Information Form Complete form online on the left, or download the form and complete by hand using the download button here.