Patient info form EF 2010

							                R A R I T A N V A L L E Y P S Y C H I A T R I C C A R E , P. C .
                                ELLA FRIEDMAN, MD
Please fill this form carefully, as it will be used for billing with your insurance company.
* - Indicates mandatory information you need to provide.
ARE YOU SELF-PAID?           YES         NO              If yes, please complete only patient information for patient chart.

PATIENT INFORMATION:
*Last Name:                                           *First Name :                                               Middle Init:

*Date Of Birth (MM/DD/YY) :                          Sex: M         F

*Street Address:

*City:                                 *State:                      *Zip:                  *Phone: (         )

*Patient relationship to Insured: SELF            Spouse        Child       Other

I AUTHORIZE use of' this form on all my insurance submissions and the release of information to my Insurance
company. I understand that I am responsible for the full amount of my bill for services provided.

INSURED’S INFORMATION. Enter “SAME” in this section, if Patient is the same person as a main Insured person.

* INSURED’S ID# :                                                            SSN:
We always recommend providing SSN together with ID# due to the fact that some insurers still utilizing it.

*Policy Group:                                       Employer Name:
*Insurance Plan Name (*Mental Health Provider):
*Address for Mental Health Claims Submission, P.O. Box/Street Address:
*City:                                 *State:                      *Zip:

Is there another Health Benefits Plan:            Yes               NO            If Yes, provide information on reverse side

*Insured Last Name:                                          *First Name:                                        Middle Initial:
*Date Of Birth (MM/DD/YY) :                                                           Sex: M        F
*Street Address:
*City:                                  *State:                   *Zip:                  *Phone: (      )


ACKNOWLEDGEMENT FORM:

I AUTHORIZE direct payment to my service provider and hereby permit a copy of this form to be used in place of
an original.
In the event that your account goes to collection, there will be a 20% collection fee added to your balance. There is a 24-
hour cancellation policy. Cancellations with less than 24 hours notice will incur a charge at insurance payment
rate, which will be billed to the Responsible Party, as it is not billable to insurance. Office Policy requires 72 hours
notice for prescription refills.
*Patient Signature:                                                         *Date:


I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

*Patient Signature:                                                          *Date:




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                                              PHONE (732) 469-7899 • FAX (732) 563-9922
                                                    HTTP://WWW.RVPSYCHCARE.COM
                                                   DRFRIEDMAN@RVPSYCHCA RE.COM