MCCOMBS COUNSELING & CONSULTING, INC.
Clinician: ______Date: ______
PATIENT INFORMATION:
Name: (First)______MI:______Last:______DOB:______
Address:______City/State/Zip:______
Social Security #:______Gender: □ (M) □ (F) Referral Source:______
Employer:______Address:______
Contact Information: Home Phone:______Mobile Phone:______Other:______
E-Mail:______Preferred Contact (check one) ____Home, ____Mobile_____Email_____Other
RESPONSIBLE PARTY: (If other than patient)
Name:______Relationship:______Phone #:______
Address (if other than above)______
Employer:______Social Security #:______DOB:______
EMERGENCY CONTACT:
Name:______Relationship:______Phone #:______
PRIMARY CARE PHYSICIAN:
Name:______Address:______Phone #:______
INSURANCE INFORMATION:
Primary Insurance Company Name:______Policy ID #:______
Authorization Number: ______Co-pay: ______# of Visits Authorized:______
Secondary Insurance Name:______Policy ID #:______
I request payment of authorized insurance benefits to be made on my behalf to McCombs Counseling & Consulting Inc. for any services furnished to me. I hereby authorize my clinician at McCombs Counseling & Consulting, Inc. to administer such treatment as may be deemed necessary or advisable and to provide such information to the above named Insurance or managed care company as may be required by them to process payment of claims on authorized visits. Payment is due when services are rendered. Some services may not be covered by insurance. I agree to pay any applicable co-pay or outstanding client balance prior to being seen by my clinician. I understand that I am ultimately responsible for my bill and any delinquent balance will be turned over to a third party for collection.
I have received a copy of McCombs Counseling & Consulting, Inc’s Notice of Privacy Practices and have read and signed the release concerning Court Appearances. I have read the General Statement Regarding Minors and Court Orders (if applicable) and am aware a copy will be provided upon my request. I understand if I request a letter or other correspondence to be written by a clinician, a minimum notice of 72 hours is required. I must also sign a release of information prior to any consultation with an outside party on my behalf. A fee of $50.00 for each letter must be received prior to release of any correspondence.
I understand that reminder notices are a courtesy of McCombs Counseling & Consulting Inc. and regardless of whether I receive a reminder contact; I am responsible for keeping any scheduled appointments or if I am unable to attend canceling any scheduled appointment with a minimum advance notice of 24 hours. I also understand that if I am unable to give 24 hours notice or do not appear for my scheduled appointment I will be responsible for a “no show/late cancellation” charge of $50.00
Signature of Responsible Party:______Date:______
MCCOMBS COUNSELING & CONSULTING, INC.
Clinician: ______Date: ______
PATIENT INFORMATION:
Name: (First)______MI:______Last:______DOB:______
Address:______City/State/Zip:______
Social Security #:______Gender: □ (M) □ (F) Referral Source:______
Employer:______Address:______
Contact Information: Home Phone:______Mobile Phone:______Other:______
E-Mail:______Preferred Contact (check one) ____Home, ____Mobile_____Email_____Other
RESPONSIBLE PARTY: (If other than patient)
Name:______Relationship:______Phone #:______
Address (if other than above)______
Employer:______Social Security #:______DOB:______
EMERGENCY CONTACT:
Name:______Relationship:______Phone #:______
PRIMARY CARE PHYSICIAN:
Name:______Address:______Phone #:______
INSURANCE INFORMATION:
Primary Insurance Company Name:______Policy ID #:______
Authorization Number: ______Co-pay: ______# of Visits Authorized:______
Secondary Insurance Name:______Policy ID #:______
I request payment of authorized insurance benefits to be made on my behalf to McCombs Counseling & Consulting Inc. for any services furnished to me. I hereby authorize my clinician at McCombs Counseling & Consulting, Inc. to administer such treatment as may be deemed necessary or advisable and to provide such information to the above named Insurance or managed care company as may be required by them to process payment of claims on authorized visits. Payment is due when services are rendered. I agree to pay any applicable co-pay or outstanding client balance prior to being seen by my clinician. I understand that I am ultimately responsible for my bill and any delinquent balance will be turned over to a third party for collection.
I have received a copy of McCombs Counseling & Consulting, Inc’s Notice of Privacy Practices and have read and signed the release concerning Court Appearances. I have read the General Statement Regarding Minors and Court Orders (if applicable) and am aware a copy will be provided upon my request. I understand if I request a letter or other correspondence to be written by a clinician, a minimum notice of 72 hours is required. I must also sign a release of information prior to any consultation with an outside party on my behalf. A fee of $50.00 for each letter must be received prior to release of any correspondence.
I understand that reminder notices are a courtesy of McCombs Counseling & Consulting Inc. and regardless of whether I receive a reminder contact; I am responsible for keeping any scheduled appointments or if I am unable to attend canceling any scheduled appointment with a minimum advance notice of 24 hours. I also understand that if I am unable to give 24 hours notice or do not appear for my scheduled appointment I will be responsible for a “no show/late cancellation” charge of $50.00
Signature of Responsible Party:______Date:______
MCCOMBS COUNSELING & CONSULTING, INC.
Clinician: ______Date: ______
PATIENT INFORMATION:
Name: (First)______MI:______Last:______DOB:______
Address:______City/State/Zip:______
Social Security #:______Gender: □ (M) □ (F) Referral Source:______
Employer:______Address:______
Contact Information: Home Phone:______Mobile Phone:______Other:______
E-Mail:______Preferred Contact (check one) ____Home, ____Mobile_____Email_____Other
RESPONSIBLE PARTY: (If other than patient)
Name:______Relationship:______Phone #:______
Address (if other than above)______
Employer:______Social Security #:______DOB:______
EMERGENCY CONTACT:
Name:______Relationship:______Phone #:______
PRIMARY CARE PHYSICIAN:
Name:______Address:______Phone #:______
INSURANCE INFORMATION:
Primary Insurance Company Name:______Policy ID #:______
Authorization Number: ______Co-pay: ______# of Visits Authorized:______
Secondary Insurance Name:______Policy ID #:______
I have read the disclosures on the reverse side of this document and agree to the terms and conditions, including financial reimbursement, insurance claims, cost and time constraints outlined in this document. I agree to abide by these policies as witnessed by my signature below:
Signature of Responsible Party:______Date:______
I request payment of authorized insurance benefits to be made on my behalf to McCombs Counseling & Consulting Inc. for any services furnished to me. I hereby authorize my clinician at McCombs Counseling & Consulting, Inc. to administer such treatment as may be deemed necessary or advisable and to provide such information to the above named Insurance or managed care company as may be required by them to process payment of claims on authorized visits. Payment is due when services are rendered. I agree to pay any applicable co-pay or outstanding client balance prior to being seen by my clinician. I understand that I am ultimately responsible for my bill and any delinquent balance will be turned over to a third party for collection.
I have received a copy of McCombs Counseling & Consulting, Inc’s Notice of Privacy Practices and have read and signed the release concerning Court Appearances. I have read the General Statement Regarding Minors and Court Orders (if applicable) and am aware a copy will be provided upon my request. I understand if I request a letter or other correspondence to be written by a clinician, a minimum notice of 72 hours is required. I must also sign a release of information prior to any consultation with an outside party on my behalf. A fee of $50.00 for each letter must be received prior to release of any correspondence.
I understand that reminder notices are a courtesy of McCombs Counseling & Consulting Inc. and regardless of whether I receive a reminder contact; I am responsible for keeping any scheduled appointments or if I am unable to attend canceling any scheduled appointment with a minimum advance notice of 24 hours. I also understand that if I am unable to give 24 hours notice or do not appear for my scheduled appointment I will be responsible for a “no show/late cancellation” charge of $50.00