Tel: 757-486-6955
Barbara Barbara Paige, Ph.D ٠ Laura Dorris, LPC • Alicia Woodworth, NCC, LPC
Thomas Baker, LCSW • Amy Courtney, MS
/ 101 North Lynnhaven Rd, Suite 103
Virginia Beach, Virginia 23452
Patient Information
Date: / New Patient / Update
Patient:
Last / First / MI / Preferred / Title
Male Female / Single Married Divorced Widowed
Patient Date of Birth: / Patient SSN:
Address:
Address Line 1
Home:
Address Line 2 / Cell:
Other:
City / ST / ZIP Code / Pager:
E-Mail: / Fax:
Referral? / Yes No / Referred by:
Spouse’s Name: ______DOB: ______Social Security #: ______
emergency Information
In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:
Tel:
Name / Relationship
employment Information
Employer: / Occupation:
Address:
Work: / X
Fax:
City / ST / ZIP Code
E-Mail:
insurance Information
Subscriber:
Last / First / MI / Preferred / Title
Subscriber Date of Birth: / Subscriber SSN:
Subscriber Employer:
Patient Relationship to Subscriber: / Self Spouse Child Other
Primary Insurance Carrier:
Group/Policy No.: / ID No.:
Address: / Tel:
Toll-free:
Fax:
City / ST / ZIP Code
Secondary Insurance Carrier:
Group/Policy No.: / ID No.:
Address: / Tel:
Toll-free:
Fax:
City / ST / ZIP Code
primary physician Information
Physician: / Telephone:
Clinic/Facility:
Please read the following carefully and sign:
- I understand as a courtesy this office will file claims for services rendered here to my insurance company. I am responsible
- for supplying all necessary forms and information for the purpose of filing insurance and advising your office immediately of
- any changes.
- I understand that I am responsible for all fees for services rendered regardless of expected coverage of my insurance. I
- agree to pay deductibles and copayments at the time of the visit unless other arrangements are made with my therapist.
- I agree to pay all expenses incurred in collecting unpaid fees and reasonable attorney’s fees up to 40% and interest if
- applicable.
- I agree to give this office at least 24 hours advance notice of cancellation or I agree to pay for the missed appointment.
- My signature below also constitutes authorization for my insurance company to assign all benefits and authorization for the
Release of any information required by my insurance company to process the claim. I understand that my therapist may be
required to disclose information from my medical record (protected health information as described in the notice of privacy
practices) to my insurance company in order to secure payment and to comply with insurance company procedures such as
utilization review and determinations of medical necessity.
- I have read and understood the above policy and agree to comply with its terms and conditions as presented.
______
(Signature of patient if adult) (Signature of responsible party)
______
(witness and date)