Patient Registration Information

(PLEASE PRINT CLEARLY AND COMPLETE ALL ( PAGES)

PATIENT OR RESPONSIBLE PARTY INFORMATION :

LAST NAME_________________________________ FIRST NAME_____________________________ M. I._____

ADDRESS _________________________________ CITY_________________ STATE________ ZIP_____________

TELEPHONE: HOME (_______)_____________ WORK (_______)_______________ CELL (_______)_____________

                          PAGER (_______) _______________ EMAIL_____________________________________

AGE ______ DATE OF BIRTH_______________ SEX ________ SOCIAL SECURITY NO. ________-______-________

MARITAL STATUS: (circle)  MARRIED      SINGLE         DIVORCED         WIDOWED

STUDENT STATUS: (circle):  FULL-TIME        PART-TIME         NONSTUDENT

EMPLOYMENT STATUS: (circle) :  FULL-TIME        PART-TIME       RETIRED      DISABLED     UNEMPLOYED

EMPLOYERS NAME ________________________________________________________________________

EMPLOYERS ADDRESS_________________________________  CITY, STATE, ZIP___________________________

In Case of an emergency notify______________________________________________________________________

Relationship: ________________________________________________ Telephone: __________________________

PRIMARY INSURANCE COMPANY: _________________________________________________________________

PATIENT’S INSURANCE ID#: ______________________________________________________________________

INSURANCE PLAN  NAME: _________________________   INSURANCE GROUP NUMBER:____________________

PREAUTHORIZATION NUMBER (If applicable): _______________________________________________________

PATIENT INFORMATION  (Only fill out if different than above) :

LAST NAME___________________________________ FIRST NAME____________________________ M. I.______

RELATIONSHIP TO PATIENT:  ___; Spouse;  ___; Child; ___; Step-Child;  ___; Other _________________________

AGE _______ DATE OF BIRTH____________ SEX _________ SOCIAL SECURITY NO. ________-______-__________

ADDRESS __________________________________ CITY________________ STATE_________ ZIP_____________

TELEPHONE: HOME (_______)______________ WORK (_______)_______________ CELL (_______)_____________

POLICYHOLDER’S  INSURANCE ID#: _________________________________________________________________

MARITAL STATUS: (circle):  MARRIED   SINGLE         DIVORCED         WIDOWED

STUDENT STATUS: (circle) :   FULL-TIME        PART-TIME         NONSTUDENT

EMPLOYMENT STATUS: (circle)    FULL-TIME        PART-TIME       RETIRED      DISABLED     UNEMPLOYED

EMPLOYERS NAME _____________________________________________________________________________

EMPLOYERS ADDRESS_______________________________ CITY, STATE, ZIP_____________________________

Have you been in treatment (for mental health issues and/or drug/alcohol) before?

CIRCLE) YES  NO  (If yes, please complete information below:

MEDICATIONS: (Please list medications you are presently taking):

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THE UNDERSIGNED UNDERSTANDS AND AGREES:

Ø      Your insurance is billed as a courtesy.  If payment is refused, for any reason, you are responsible for payment of charges in full.

Ø      Payment is due at the time of the session by cash or check (credit and/or debit cards are not accepted). A $25.00 fee will be charged for all checks returned by the bank for NSF or any other reason (payment is due before any further sessions).

Ø       Sessions not canceled or rescheduled twenty-four (24) hours in advance will result in a charge to the patient of $50.00.

Ø       I understand if I am more than 20 minutes late for your scheduled appointment, I may not be seen that day and will be charged $50.00.  Please attempt to call if you will be more than 10 minutes late.

Ø       I understand that my insurance company may be charge for missed appointments or appointment not rescheduled in time. I understand that it is my responsibility to reimburse the insurance company in this event.

Ø       I understand it is my responsibility to obtain information about whether my insurance carrier covers the services rendered.

Ø        I am also responsible for obtaining initial authorizations for treatment and information about my copayment and deductible.

Ø       Any costs (i.e. collection/legal fees) incurred in the collection of delinquent payments will be added to the original charges, in addition to a $25.00 administration fee.

Ø       I will inform Dr. Drydyk in writing of any changes in address, telephone numbers, and/ or Insurance Coverage.

Ø       Additional Fee’s are:  $25.00 for report writing, forms to be filled out, consultation with others, etc.

Ø       The therapeutic session is 40-45 minutes long from the scheduled time of start of the appointment.

Ø       The patient or guardian if the patient is a minor, consents to counseling, psychological and psychiatric treatment, understanding that such treatment may or may not be of benefit.

Ø       I understand that Dr. Drydyk is a treating psychologist and will not perform in a forensic capacity.

Ø       I have read the "Hippa Privacy Information" on the webpag "www.drydyk.com" and agree.

Please Print Patient’s/Responsible Parties Name: ___________________________________

Signature of Patient/Guardian/ Responsible Party:

_____________________________________________________ Date: __________________

                                      (Please Sign Name and date)

(Please Circle  Relationship to patient( must be 18 years of age or older)):

Patient;  Parent;  Legal Custodial Parent;  Guardian