ALEXIANBROTHERSCENTER FOR MENTAL HEALTH APPLICATION

PLEASE COMPLETE ALL SPACES ON BOTH SIDES

ALL INFORMATION SHOULD PERTAIN TO CLIENT

Date:

Client’s Name: (Please provide your full legal name)

Client’s Social Security #: Client’s Mother’s Maiden Name:

Address:

StreetApt. #CityStateZip

Home Phone:( ) Work Phone: ( )

Age: Date of Birth: Sex:  Male  Female

Occupation: Employer Name:

Employer’s Address: Street City State Zip

Client’s Gross Annual Income $ Family Gross Annual Income: $Current Employment Status:  Full Time  Part Time  Unemployed  Retired  Homemaker

 Student  Other:

Race:  White/Caucasian  Black/African American  American Indian  Asian  Pacific Islander

 Other:

Is the client of Hispanic Origin?  Yes  No

If yes, what is client’s origin?

 Mexican  Puerto Rican  Cuban  Central or South American  Other:

Is the client a U.S. Citizen?  Yes  No

Religion/Spiritual Orientation:

Marital Status:  Never married  Married  Widowed  Divorced  Separated

 Domestic Partner  Other:

Education: Please circle the highest grade completed

0 1 2 3 4 5 6 7 89 10 11 1213 14 15 1617 18 19 20

ElementaryHigh SchoolCollegeGraduateSchool

Emergency Contact:

NameRelationshipPhone number

Does the client live alone?  Yes No If No, please complete the information below.

Family members living in the home or others living in the home:

Name / Relationship / Age / Date of Birth

BILLING AND INSURANCE INFORMATION

Please present all insurance cards (Private insurance, Medicare, or Public Aid) to the receptionist. They will be copied for our records.

Does the client have Medicare Health Insurance?  Yes  No If yes, Medicare #:

Does the client have a Medicaid Card?  Yes  No If yes, Medicaid #:

Does the client have Private Insurance?  Yes  No If yes, fill out the following information.

Insurance Company Information

Primary Insurance Co. Group/Policy #

Name of Insured ID #

Insurance Company Telephone # ( )

Secondary Insurance Co. Group/Policy #

Name of Insured ID #

Insurance Company Telephone # ( )

Does someone else manage your bills?  Yes  No

Assignment of Benefits/Agreement to Pay
I hereby assign payment of authorized Medicare benefits and any other medical and/or surgical benefits, to include major medical benefits to which I am entitled, to be made either to me or on my behalf to AlexianCenter for Mental Health or any service furnished me by that physician/supplier. I authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services.
  • This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release information necessary to secure payment.
  • I authorize AlexianCenter for Mental Health to release medical information about me that may be needed to submit and obtain payments from a working agreement payment source.
  • I understand that I am responsible for payment of charges that are not covered by insurance or any other funding source. This includes charges for checks returned due to non-sufficient funds.

SignatureDate

Relationship to client

Witness signatureDate

OFFICE USE ONLY

State EnteredMed Mgr Entered

Fee:Evaluator: Prog:

ALEXIANBROTHERSCENTER FOR MENTAL HEALTH Client Name

3436 N. Kennicott Ave. Client I.D.#

ArlingtonHts., IL 60004rev. 12/5/05, 11/6/08, 3/28/12