Stephen Rothenberg, Psy.D.
75 Arlington Street, Suite 500, Boston, MA. 02116
Phone: 617/274-8734 Fax: 617/507-8343 Email: firstname.lastname@example.org
Welcome.Please take a few minutes to provide the following information:
Birth Date (MM/DD/YYYY)
Blue Cross Blue Shield
Insurance ID Number:
Other Insurance Company (If not using insurance, enter "self-pay")
Insurance Company Address
Please enter credit card. This will only be used for missed appointments.
Name of cardholder
Expiration Date MM/YY
Primary Care Physician:
Subscriber Name and DOB:
Person responsible for any amount not covered by insurance:
Please briefly describe the reason for this visit
INSURANCE AUTHORIZATION AND ASSIGNMENT: I hereby authorize the provider
of service to furnish information to insurance carriers concerning my
condition and treatment I hereby assign to the provider all payments
for medical services rendered to myself or my dependents. I UNDERSTAND
THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE.
Your signature below indicates that you have received and read the Psychotherapist-Patient agreement in its entirety and agree to its terms. It also serves acknowledgment that you have received the HIPPA notice form described above. If there any portions of the agreement that are unclear, it is your responsibility to ask her therapist for clarification prior to signing this form.