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I authorize Arohi Counseling
Authorization to disclose or obtain confidential client information
By Signing This Form, I Understand The Following
Due To The New Federal Patient Confidentiality Laws (Hipaa)
Acknowledgment Of Our Notice Of Privacy Practices
Reviews
Contact Us
Home
About Us
Training
Training for Therapists
Leadership Development Program
Resources
Forms
Registration Form
I authorize Arohi Counseling
Authorization to disclose or obtain confidential client information
By Signing This Form, I Understand The Following
Due To The New Federal Patient Confidentiality Laws (Hipaa)
Acknowledgment Of Our Notice Of Privacy Practices
Reviews
Contact Us
(610) 457-7640
Today’s Date Primary Care Provider
Primary Care Provider
Patient’s Last Name:
Marital Status:
Single
Mar
Div
Sep
Wid
Social Security #:
Maiden Name:
Birth Date:
Age:
Sex:
M
F
Home Phone #:
Alternate phone:
Emergency Contact:
Emergency Contact #:
Occupation:
Employer:
Employer phone #:
Referral Source:
Email:
INSURANCE INFORMATION
Please give your insurance card to the receptionist
Person responsible for bill:
Birth date:
Address (if different):
Home phone #:
Occupation:
Employer:
Employer address:
Employer phone #:
Is this patient covered by insurance?
Yes
No
Please indicate primary insurance:
Subscriber’s Name:
Subscriber’s SS#:
Birth Date:
Group #:
Policy #:
Co-payment:
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
Name of secondary Insurance if applicable:
Subscriber’s Name:
Group #:
Policy #:
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dr. Shamsi or insurance company to release any information required to process my claims.
Date
Patient / Guardian Signature:
Submit
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