Insurance Information ACC

Your first name *

Your last name *

What is your Date of Birth * +

Name of Insurance and Plan type *

Insurance Phone # *

How much is your deductible *

Have you met your deductible for the year? *

Yes

No

Employer *

Insured’s SS# *

Driver’s License No. *

State *

Full Name of Spouse

SS#

Spouse’s Employer

Phone

Insured’s Primary Insurance *

Member ID. Number *

Group No *

Secondary Insurance *

Yes

No

Company (If applicable)

Policy No (If applicable)

Job Related Injury-Workmens Comp. Co *

Yes

No

Company (If applicable)

Office Billing and Insurance Policy

1. I authorize use of this form on all of my insurance submissions.

2. I authorize the release of information to my insurance company(s).

3. I understand that I am responsible for the full amount of my bill for services provided.

4. I authorize direct payment to my service provider.

5. I hereby permit a copy of this to be used in place of an original.

Name *

ID. No *

Date * +

Signature *

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Select Counselor *

It is your responsibility to pay any deductible amount, co-pay, co-insurance amount or any other balance not paid by your insurance the day and time serviced provided.

There will be a $25.00 service charge on all returned checks.

In event that your account goes to collections, there will be a $20 collection fee added to your balance.

There is a 24-hour cancellation policy which requires that you cancel your appointment 24 hours in advance to avoid being charged.

Signature *

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Date * +