Patient Insurance Information

Patient Name: *

Date of Birth: *

Street Address *

Town: *

State: *

Zip Code *

Telephone: *

Other phone, work/cell:

PRIMARY INSURANCE: *

Policyholder's Name: *

Policy Number: *

Policyholder's date of birth: *

Relationship to patient: *

Self

Spouse

Parent

Step-parent

Employer: *

SECONDARY INSURANCE:

Policyholder's Name:

Policy Number:

Policyholder's Date of Birth:

Relationship to patient:

Self

Spouse

Parent

Step-parent

Employer:

Insurance Claim Processing Disclaimer

I authorize the release of medical or other information necessary to process insurance claims. Such information is to be released only for the purpose of filing health insurance claims with insurance companies and related agencies. I authorize payment of medical benefits directly to Lea Lockwood, PhD, LICSW for any services rendered.

Signature *

Date *

Print Name *

Check if signing for minor:

Yes