"Client Face Sheet Template"

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Client Face Sheet
1 Patient Name
Last
First
Middle Initial
Nickname
2 Address
City
State
Zip
3 Home Phone: (
)
4. Work Phone: (
)
Ext #:
5 Soc. Sec. #:
6. Birthdate:
Age:
7. Sex: M F
8. Marital Status: S M D W
9 Employer:
Phone: (
)
Occupation:
10 Student/School:
Full Time
Part Time
11 If dependent children, are guardians
Married
Separated
Divorced
Other
12 Religion
13. Referred By:
14 IN CASE OF EMERGENCY NOTIFY:
Relationship:
Phone #: (
)
Financially Responsible Party (Guarantor) Information
(if same as patient, only complete items 6, 7, and 8)
1 Guarantor Name:
Birthdate:
Last
First
Middle Initial
2 Guarantor Address:
3 Guarantor Relationship to Patient (circle one):
Spouse
Mother
Father
Sibling
Relative
Friend
Other
4 Home Phone: (
)
5. Soc Sec. #:
6. Derivers Lic. #:
7 Guarantor's Employer:
Work Phone: (
)
Occupation:
8 Spouses Name:
9. Spouse Work Phone: (
)
***** Do You Have Insurance?
Yes
No
(If yes, please complete the following)
1 Primary Insurance Co. Name:
Phone: (
)
Insurance Co. Address:
2 Subscriber's Name:
3. Relationship to Pt.:
Self
Spouse
Parent
Other
4 Birthdate:
5. Group ID #:
6. Soc. Sec. #:
7 Secondary Insurance Co Name:
Phone: (
)
Insurance Co. Address:
8 Subscriber's Name:
9. Relationship to Pt.:
Self
Spouse
Parent
Other
Employer:
Work Ph: (
)
Occupation:
10 Birthdate:
11. Group ID #:
12. Soc. Sec. #:
13 Any Other Insurance?
ASSIGNMENT OF BENEFITS: I hearby authorize and request my insurance to pay directly to Jamie Kobsar, MA, LPC the
the amount due for services rendered to me or my dependent.
RELEASE OF INFORMATION: II authorize the release of any medical, mental health, or substance abuse information
necessary to process insurance claims for services rendered to me or my dependent. This consent is subject to recovation at
any time, except where action has already been taken on the basis of this release. Unless revoked eaerlier, this release will be
null and void six months after the final payment has been received on my account. This consent is subject to state and federal
confidentiality requirements.
Signed:
Date:
Insured
Parent/Guardian
GUARANTOR AGREEMENT: I AGREE TO TAKE FULL RESPONSIBILITY FOR THE ENTIRE AMOUNT DUE FOR ANY
AND ALL SERVICES RENDERED BY Jamie Kobsar, MA, LPC. If provider is contracted with the insurance company, I will be
responsible only for the co-pay, deductible, and non-covered services as determined by the insurance plan:
Guarantor Signature or Patient Signature (if patient is guarantor)
Date
PATIENT RELEASE OF INFORMATION TO GUARANTOR/THIRD PARTY AGENCY: I authorize Jamie Kobsar, MA, LPC
to release my financial information to my guarnator or third party agency (in case further collection assistance is required)
I do
Do not
want a copy of this release.
Client Face Sheet
1 Patient Name
Last
First
Middle Initial
Nickname
2 Address
City
State
Zip
3 Home Phone: (
)
4. Work Phone: (
)
Ext #:
5 Soc. Sec. #:
6. Birthdate:
Age:
7. Sex: M F
8. Marital Status: S M D W
9 Employer:
Phone: (
)
Occupation:
10 Student/School:
Full Time
Part Time
11 If dependent children, are guardians
Married
Separated
Divorced
Other
12 Religion
13. Referred By:
14 IN CASE OF EMERGENCY NOTIFY:
Relationship:
Phone #: (
)
Financially Responsible Party (Guarantor) Information
(if same as patient, only complete items 6, 7, and 8)
1 Guarantor Name:
Birthdate:
Last
First
Middle Initial
2 Guarantor Address:
3 Guarantor Relationship to Patient (circle one):
Spouse
Mother
Father
Sibling
Relative
Friend
Other
4 Home Phone: (
)
5. Soc Sec. #:
6. Derivers Lic. #:
7 Guarantor's Employer:
Work Phone: (
)
Occupation:
8 Spouses Name:
9. Spouse Work Phone: (
)
***** Do You Have Insurance?
Yes
No
(If yes, please complete the following)
1 Primary Insurance Co. Name:
Phone: (
)
Insurance Co. Address:
2 Subscriber's Name:
3. Relationship to Pt.:
Self
Spouse
Parent
Other
4 Birthdate:
5. Group ID #:
6. Soc. Sec. #:
7 Secondary Insurance Co Name:
Phone: (
)
Insurance Co. Address:
8 Subscriber's Name:
9. Relationship to Pt.:
Self
Spouse
Parent
Other
Employer:
Work Ph: (
)
Occupation:
10 Birthdate:
11. Group ID #:
12. Soc. Sec. #:
13 Any Other Insurance?
ASSIGNMENT OF BENEFITS: I hearby authorize and request my insurance to pay directly to Jamie Kobsar, MA, LPC the
the amount due for services rendered to me or my dependent.
RELEASE OF INFORMATION: II authorize the release of any medical, mental health, or substance abuse information
necessary to process insurance claims for services rendered to me or my dependent. This consent is subject to recovation at
any time, except where action has already been taken on the basis of this release. Unless revoked eaerlier, this release will be
null and void six months after the final payment has been received on my account. This consent is subject to state and federal
confidentiality requirements.
Signed:
Date:
Insured
Parent/Guardian
GUARANTOR AGREEMENT: I AGREE TO TAKE FULL RESPONSIBILITY FOR THE ENTIRE AMOUNT DUE FOR ANY
AND ALL SERVICES RENDERED BY Jamie Kobsar, MA, LPC. If provider is contracted with the insurance company, I will be
responsible only for the co-pay, deductible, and non-covered services as determined by the insurance plan:
Guarantor Signature or Patient Signature (if patient is guarantor)
Date
PATIENT RELEASE OF INFORMATION TO GUARANTOR/THIRD PARTY AGENCY: I authorize Jamie Kobsar, MA, LPC
to release my financial information to my guarnator or third party agency (in case further collection assistance is required)
I do
Do not
want a copy of this release.