1 / 3 Judith C. Walters, Ph.D. LP Form: 8/11/2012

1 / 3 Judith C. Walters, Ph.D. LP Form: 8/11/2012

Insurance Authorization Form

Patient Name: Initial VisitDate:

Reviewed by:___ X Date:____/____/2012______

Patient Identification Information
Date: ___04__/___24_/2012___
Patient Name: / EMAIL:
Address: Apt.# / City: / Zip:
Home Phone: / Cell Phone: / Work Phone:
D.O.B.
______/______/______/ Gender:
☐ M ☐X F / Marital Status:
☐ Never Married ☐ M ☐ D ☐ W
☐ Lives w/partner Other:______
Insurance Information
Primary Insurance:
HMO ☐, PPO ☐, Other______/ Secondary Insurance:
HMO ☐, PPO ☐, Other______
Policy # (ID): / Policy # (ID):
Subscriber Name: / Subscriber Name:
D.O.B.:
______/______/______/ D.O.B.:
______/______/______
Relationship to Patient: / Relationship to Patient:
Social Security No.:
______- ______- ______/ Social Security No.:
______- ______- ______
Employer: / Employer:

Billing Release and Payment Consent and Authorization Agreement

**All language such as the word “I” includes services authorized for an adult, or for a legal ward as authorized

by the legal guardian.

I, ______certify that I (or my dependent) have insurance coverage as named above and

I attest that this information is complete and accurate. I also affirm and acknowledge the following:

•Dr. Walters is an in-network provider with my insurer, which is UBH;

•I agree to pay the full amount of each session upon notification that my insurer failed to

Reimburse Dr. Walters.

•Sessions that run beyond 45 minutes and thereafter, an additional charge will be accrued

for any part of each fifteen minute overrun.The additional charge is to be paidby me

at the time services are rendered;

•I acknowledge that my insurer may not reimburse me for some or all of these services;

•Dr. Walters is not responsible for the performance of my insurer, and payment Is my sole

Responsibility;

•I understand and agree to pay my co-pay of $______for each session as it occurs; and

•If, for any reason, a balance is accrued, I will pay this amount in full at the time that I am notified that a balance exists;

•I understand and agree that should any balance remain unpaid for 30 days after the date of billing, and a $25.00 late fee will be added to the balance each month until paid in full;

•I will pay $100.00 for each testing Item/materials not returned promptly to the office & in good condition; and

•I have been advised that an unpaid balance of $200.00 or less may lead to suspension of services or

discharge from treatment;

•I agree that if I do contact Dr. Walters and resolve any billing issues within 10 days of the date of

billing, the charges are considered correct and true, and payment is past due;

• I agree that if I am unable to pay the fees for an appointment, that I will cancel the appointment at

least 24 hours ahead of time; and also,

•I agree to pay $60.00 for any missed appointments not cancelled 24 hours in advance.

•I have been informed that Pay Pal is available on Dr. Walters’s website: , and I can choose to pay for my appointment ahead of time,

and bring a Pay Pal receipt of payment to my appointment;

•I understand that Dr. Walters accepts checks and cash only in her office at the beginning of each session;

•I agree to participate fully in the treatment planning and to comply fully with the therapeutic process and office rules.

Patient Signature:______Date:______

Therapist Signature:______Date:______