Online Registration Form – Ephesians Professional Counseling

Ephesians Professional Counseling

REGISTRATION INFORMATION

Therapist

Last Name

First Name

DOB

Street Address

City

State

Zip Code

Phone

Email Address

SS#

Client Is:

Male Female

Marriage Status

Student?

Yes No

Briefly Describe symptons, illness or accident

Date of onset of symptoms (MM/YY)

Employed?

Yes No

Employer or Company Name

Street Address

City

State

Zip Code

Occupation

Driver's License #

Name of doctor or person who referred you and how you found us

INSURANCE INFORMATION

Please update if the Policy Holder's information is not the same as the client's

Policy Holder's Name

DOB

Phone

SS#

Street Address

City

State

Zip

Insurance Company

ID #

Group #

Insurance Phone

Effective Date

Relationship to Client

By entering my initials below I understand that Insurance coverage is not a guarantee of benefits and that determination will be made at the time the claim is received. I also understand that I am responsible for the balance if the claim is denied and also for any co-insurance or annual deductible that is applicable. All payments are due at the time of service. I also understand that I am responsible for all appointments and I will be charged a fee of $65 unless I give 24 hours’ notice of cancellations. Late fees are due at the next appointment.

Initials showing agreement to above statement

EMERGENCY INFORMATION

Who to contact in case of emergency

Name

Relationship to Client

Primary/Cell Phone

Secondary Phone (Work/Home)

Assign and Release

I authorize payment of Medical Benefits to this facility/provider. I authorize release of any medical information necessary to process the claim and/or I also request payment of government benefits either to myself or party who accepts assignment.

Who is signing?

Client Parent/Guardian/Legal Authority

Name of person Signing the form:

I acknowledge that I am 18 years old or have legal authority to sign for the Client

Yes

College Park	Bethesda
4920 Niagara Road	5910 Goldsboro Road
Suite 308	Bethesda, MD 20817
College Park, MD 20740	301-466-2050
301-439-7191
» Handicapped Accessible