Mealer Psychological, PLLC
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Patient Information Form

Name:___________________________________________  Age:______  Date of Birth:__________

Date:__________  SS#:____________________

Address:__________________________________________________________________________

City, State, Zip:_____________________________________________________________________

Telephone:  Home:___________________  Work:____________________ Cell:_________________

May we call you?  At Home: Y  N  At Work: Y  N  Cell:  Y  N

Email:_______________________________________ Permission to send email:  Y  N

Employer Name and Address: ___________________________________________________________

___________________________________________________________________________________

Emergency Contact:___________________________________________________________________

Relationship:_________________________ Phone:__________________________________________

PRIMARY INSURANCE/ADDRESS:______________________________________________________

___________________________________________________________________________________

Insurance Phone (claims):____________________ Certification:__________________________

Policy Holder:_______________________________ SS#:_________________ DOB: _____________

Relationship to Patient:____________________________ ID#:_______________ Group #:_____

Secondary Insurance/Address: _________________________________________________________

____________________________________________________________________________________

Insurance Phone (claims):____________________ Certification:__________________________

Policy Holder:_______________________________ SS#:_________________ DOB: _____________

Relationship to Patient:____________________________ ID#:_______________ Group #:_____

INSURANCE AUTHORIZATION AND ASSIGNMENT:
I authorize Cynthia Z. Mealer, Ph.D., William F. Mealer, Ed.D., or their agents, to furnish my insurance carrier(s) information they may request concerning my own or my dependent's treatment.  I assign to Mealer Psychological, PLLC or to Dr. Mealer all payments for services rendered myself or my dependents.  I understand my rights under HIPPA  and confidentiality.  I understand that I am financially responsible for any amount not covered by insurance.  All charges are due and payable at the time of service.

Signature:__________________________________________  Date:_____________________________




Agreement:

I have read and understood the practice policies of Mealer Psychological, PLLC and information regarding HIPPA rights and confidentiality.  I have had the opportunity to ask any questions or address any concerns.
I agree to the practice policies of Mealer Psychological, PLLC

Signature:  ______________________________________________________________  Date:_____________________________________________

Please complete the following:

Referred by:_____________________________________________________________ May I acknowledge this referral?  Y  N

Primary Physician/Phone:________________________________________________________________________
May I have your permission to contact this Doctor to coordinate care?  Y  N

Psychiatrist/Phone:______________________________________________________________________
May I have your permission to contact this Doctor to coordinate care?  Y  N

Signature:________________________________  Date:_____________________________

Previous Psychological/Psychiatric Treatment:



Significant Medical History:



Medications:



Why are you seeking therapy at this time?


PRE-AUTHORIZED HEALTH CARE FORM

This form allows Dr. Mealer to charge your credit card for copays so that you do not have to remember cash or a check at each appointment.

Your information will be kept separately from your clinical record in a secure and private location.
Balances may also be charged to a credit card if you prefer.

I authorize Dr. Mealer to keep my signature on file and to charge my account for balances of charges not paid by insurance for services provided including late cancellations and no show charges.

__ Recurring charges of $__________ (copay amount) for each appointment beginning on __________.

I understand that this form is valid for four (4) years unless I cancel the authorization through written notice to Dr. Mealer.

Patients Name: ______________________________________________________________________________________

Card Holders Name:___________________________________________________________________________________

Billing Address:_______________________________________________________________________________________

City:__________________________________  State:_____________  Zip Code:__________________________________

__Visa  __MC  __Discover

Account #:___________________________________________________________________________________________

3-digit security code (on back of card):___________   Expiration Date:_____/_____/_____

Signature:_________________________________________________________
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