Insurance Information

Complete this section if you plan on using your insurance to pay for services. Please note that the majority of insurance carriers reserve the right to access your records as a way to ensure proper utilization and treatment. In most cases, your insurance policy and my agreement with them allows for this record review. If you do not want your personal information shared with your insurance company you can elect to pay for services yourself.

Primary Insured _______________________________________________________

Primary Insured date of birth and SSN: _____________________________________________________

Insurance Company Name: _______________________________________________________________

Insurance Company Address: ____________________________________City______________________

State _____ Zip ____________ Phone ______________________________

ID#: _____________________ Group#: ____________________

Authorization: ____________________