Insurance Information Update and Consent to Treatment

Client Name

First NameMiddle InitialLast Name
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Will Bay Area Psychological Consultants be filing insurance on your behalf?
Primary Insurance Carrier
Primary Insurance Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Insurance Policy Number/Member ID
Primary Insurance Group Number
Primary Policy Holder Name

First NameMiddle InitialLast Name
Primary Insurance Policy Holder's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Insurance Policy Holder's Relationship to Client:

Other
Has policy coverage for Bay Area Psychological Consultants been verified with the insurance carrier by client?
Secondary Insurance Carrier
Secondary Insurance Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Insurance Policy Number/Member ID
Secondary Insurance Group Number
Secondary Insurance Policy Holder Name

First NameMiddle InitialLast Name
Secondary Insurance Policy Holder's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Insurance Policy Holder's Relationship to client:

Other
Has policy coverage for Bay Area Psychological Consultants been verified with the insurance carrier by client?
Please be informed that Bay Area Psychological Consultants files insurance as a courtesy and it is in no way a guarantee that your insurance company will pay for services rendered. All claims are subject to the written conditions of your policy. You, as the client, are ultimately responsible for the account and any follow-up contact needed with your insurance carrier. Your signature is required in order to file insurance and receive services.

I agree to assign all insurance benefits not to exceed total charge to my provider at Bay Area Psychological Consultants. I agree for any information to be released to insurance companies and/or sponsoring agencies for the purpose of verifying outpatient and/or inpatient diagnosis, treatment and other data. I hereby agree to be responsible for the cost of any non-covered services as notified by a periodic statement and my explanation of benefits.

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered at the time of service.
I, the undersigned party, do hereby give my consent to the clinicians of Bay Area Psychological Consultants in the capacity of psychotherapist/psychologist for treatment of First Name Last Name.
Signature of Client or Parent/Guardian
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Individual signing form if not Client

First NameLast Name
Relationship to Client
Parent/Guardian/Power of Attorney
Please take or upload a photo of Primary Insurance ID Card
Please take or upload a photo of Secondary Insurance ID Card
Please Take or Upload a Photo of a State Issued ID Card of Client/Parent or Guardian
Should be Empty: