Shorehaven Behavioral Health, Inc.
CLIENT REGISTRATION FORM AND PAYMENT PLAN
Client’s Name ________________________________________________
Date of Birth:____/____/___ – Sex: M F
Address:_________________________________________________________
Phone:(______)______________________
City: ________________________ State/Country: _____ Zip/Postal Code: _________ Soc. Sec. No.:________________________
If working, Employer:___________________________________
Business Phone:______________
Occupation:______________________________
Employer Address:___________________________________
City:_____________ State:_________ Zip:_____________
CHECK IF: Parent___ Spouse___
Name ___________________________ Date of Birth:__/__/__ – Sex: M F
Phone:(____)________
Employer:______________________________________
Business Phone:_____________
Occupation:______________________
Employer Address:___________________________________
City:_____________ State:_________ Zip:_________
If patient is child, other Parent : _______________________________
Date of Birth:___/___/___ – Sex: M F
Phone:(____)________
Address if Different: __________________________________
City:_____________ State:_________ Zip:____________
Employer:______________________________________
Business Phone:_____________
Occupation:____________________
Employer Address:___________________________________
City:_____________ State:_________ Zip:__________
Emergency Information:
Name of Closest Relative:_____________________________________
Relationship:_________________________
Phone:(_____)______________
Address:________________________________
City:_____________ State:______ Zip:__________
Primary Insurance Plan:
Subscriber:____________________________
Insurance Company: ____________________________
Subscriber No.:_______________________________
Group No.:__________________________
Secondary Insurance Plan:
Subscriber:____________________________
Insurance Company:_____________________________
Subscriber No.:_______________________________
Group No.:__________________________
Primary Insurance Plan Address for Claims
Street or P.O. Box:____________________________________
City:____________________ State/Country:_______________
Zip/Postal Code:_______
Phone Nos:____________________
Secondary Insurance Plan Address for Claims:
Street or P.O. Box:____________________________________
City:____________________ State/Country:________
Zip/Postal Code:_______
Phone Nos:____________________
Payment Plan: Select the most appropriate payment plan according to your needs and resources. (Initial your plan choice.)
1.____I will pay the usual and customary fee (or a negotiated rate) at each session by cash or check OR by credit card: (circle) Visa MC Card No.______________________________ Expiration:_____/____.
A receipt will be sent to me.
2.____I will submit the bill to my insurance company myself and collect from my insurance myself, and I will pay
the usual and customary fee at each session.
3.____SBH will bill my insurance and I will pay any amounts which the insurance does not pay, such as deductibles and co-payments, or for which my insurance is not responsible. If insurance benefits are exhausted, I will pay the usual fee. I will pay any co-payments at each visit. (For Medicaid, Badgercare, & Medicare, choose this option.)
4.____Other agreement negotiated with therapist:
Payment Plan Agreement. I make this agreement with the knowledge and understanding that I accept full responsibility and liability for any and all charges incurred and guarantee timely payment of the agreed upon charges. I also understand that I will be liable for any costs associated with collection activities necessitated by delinquent outstanding charges, including costs levied by collection agencies, legal fees, search fees, or other related collection costs. Bank charges for bounced checks will be charged at the customary rate charged by SBH's bank. SBH may charge interest (1.5%/month) on unpaid balances delinquent commencing one month following a notification letter being sent to me. Cancellations. If for any reason an appointment cannot be kept, therapist must be notified one day in advance or the customary charge will be made. Missed appointments cannot be billed to insurance.
Authorization to Bill. My signature below authorizes Shorehaven Counseling Associates, Inc., (SBH) (1) to file insurance claims with my insurer for services provided to patient without obtaining my signature on each and every claim to be submitted and (2) to release any information needed to process my insurance claims or to collect on my bill and (3) to bill the charge card listed above.
Assignment of Benefits. I authorize my insurance carrier to pay, and I hereby assign, directly to SBH all benefits from my insurance for services provided by SBH.
Signature:____________________________________________________ Date:____/____/_______
(Parent or patient if over 18)
Signature:_____________________________________________________ Date:____/____/_______
(second patient or parent, if responsible for payment)