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:_____________________________
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:_____________________________________________
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?
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:_________________________________________________________
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:_________________________________________________________
