Address

Home Phone
- Area Code Phone Number
Work Phone
- Area Code Phone Number
Birth Date
Month Day Year
Employer
Employer Address
Employer Telephone
Referred By
Billing Information
Person Responsible for payment of bill (if different from above))
First Name Last Name

Address of Person of payment

Address for sending claims

ID Number
Group Number
Phone Number for Insurance Co.
- Area Code Phone Number
Deductible?

Yes No
Deductible Amount
Co Pay?
Secondary Medical Insurance Co.
Assignment of Benefits
I hereby assign mental health/psychotherapy benefits to which I am entitled (including Medicare, private insurance, and other health plan benefits) to The Integral Psychology Center. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original copy. I understand that I am financially responsible for all charges. I hereby authorize said assignee (The Integral Psychology Center) to release all information necessary to secure payment on my behalf.

Yes
Should be Empty:

Integral Psychology Center - Online Billing FormClient Information

Billing Information