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Unformatted text preview: [ FORM 28 Use the top of this page for your letterhead.] Financial Information Form I truly appreciate your choosing to come to me for psychological help. As part of providing high-quality services, we need to be clear about our financial arrangements. n If you have health insurance, it may pay for a part of the cost of your treatment here. To find out if this is so, my staff and I need the information requested below. We will explain any part of this form that you do not under- stand. n If you have no health insurance coverage, or do not intend to use it, please check here q , complete sections A and E below, and return this form to me or my secretary. A. Patients name: Birthdate: Soc. Sec. #: Address: Home phone: (If the patient is a dependent) Insureds/policy holders name: Occupation: Employer: Work phone: Address of employer: B . (If applicable) Spouses name: Birthdate: Soc. Sec. #: Occupation: Employer: Work phone: Address of employer: C. If you (or your spouse) have any of these kinds of insurance, please fill in the numbers and names for each one. 1. Blue Cross/Blue Shield Name of subscriber (if different from patient): Identification/agreement/policy #: Group or enrollment #: Plan #/code or BS #: Effective date: Location of plan: Reciprocity #: Phone: Providers phone: 2. Commercial health insurance carrier/company2....
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This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.
- Spring '10