Kathryn B. Miller, PhD
Licensed Psychologist
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Registration Form
Patient Information
Patient Name Date of Birth
Last Name First Name Initial
Street Address
City State ZIP
Home Phone: Work Phone: Cell Phone:
Soc. Sec. # Emergency Contact
Sex:
Female Male Age
Marital Status:
Single Married Partnered Divorced Separated Widowed
Employer Occupation
Referred by May we acknowledge this referral?
Primary Insurance
Primary Insurance Company Phone :
Ins Claims Address City State Zip
Policy / Member ID Group/Account #
Policy Holder Information:
(if the patient is not the employee/policy holder)
Name Date of Birth Relationship
Last Name First Name Initial
Street Address
City State ZIP
Soc. Sec. # Employer
Secondary Insurance
Secondary Insurance Company Phone :
Ins Claims Address City State Zip
Policy / Member ID Group/Account #
Policy Holder Information:
(if the patient is not the employee/policy holder)
Name Date of Birth Relationship
Last Name First Name Initial
Street Address
City State ZIP
Soc. Sec. # Employer
Responsible Party
(Where should the patient’s portion of the bill be sent, if not to the patient?)
Name Relationship
Last Name First Name Initial
Address Phone:
Assignment and Release
I the undersigned, certify that I (or my dependent) have insurance coverage as noted above and assign directly to the healthcare
provider listed at the top of this form all insurance benefits, if any, otherwise payable to me for services rendered. I understand
that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the healthcare provider to
release all information necessary to secure the payment of benefits and to mail patient statements. I authorize the use of this
signature on all insurance submissions.
Responsible Party Signature Relationship Date
Date
DX Code
click to sign
signature
click to edit
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