session with a copy of your insurance card.

NAME:  
_______________                                                                                                                                       
ADDRESS:
___________________________________                                                                                            
                                                                                                                                  
HOME PHONE #:  _______________   CELL _____________      WORK _______   
    
DATE OF BIRTH:   ___/___/_______     SEX: ____        MARITAL STATUS:    _______   

SOCIAL SECURITY#: _____/___/______            EMPLOYER:   _________________  

Email ____________________________________   

CLAIMS ADDRESS:  get from insurance card make sure you get the mental health
address                                           

_________________________________

________________________________

_______________________________                                                                                             
                                              

                                                                                                                                

PRIMARY INSURANCE INFORMATION:
INSURANCE CARRIER:  ________________
________                                                                                           
I.D.#:  ____________________                                   GROUP #:     ____________
       
BENEFIT’S PHONE #:                                                 AUTHORIZATION PHONE #:
__________                  
SUBSCRIBER:   ________________________           RELATIONSHIP TO PATIENT:  
_______                      
SUBSCRIBER’S DATE OF BIRTH: ___________           SUBSCRIBER’S  S.S. #:
____/___/_____

SECONDARY INSURANCE INFORMATION:
INSURANCE
CARRIER:                                                                                                                                     
I.D.#:                                                                                  GROUP
#:                                                                   
BENEFIT’S PHONE #:                                                  AUTHORIZATION PHONE
#:                                
SUBSCRIBER:                                                                 RELATIONSHIP TO
PATIENT:                               
SUBSCRIBER’S DATE OF BIRTH:                               SUBSCRIBER’S  S.S.
#:                                              





I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO BRYAN F. GRANELLI, Ph.D.
FOR SERVICES RENDERED.
                                                                                                                                 
SIGNATURE                                                                                                                      DATE

Please call your insurance company to determine if services need to be pre authorized