No

Cell Phone
Is it OK to leave you a message?

Yes

No

Work Phone
Is it OK to leave you a message?

Yes

No

Email Address
Is it OK to leave you a message?

Yes

No

Social Security #

Date of Birth

Emergency Contact Name
Phone #

Source of Payment

Insurance

Self Pay

Type of Insurance
Policy #
Group #
Cardholder’s Name
Cardholder’s DOB
Cardholder’s Social Security #
Employer Address
City
State
Zip
Relationship to Client

I hereby authorize, to release to my insurance company or its representative, any information regarding my treatment, including diagnosis, necessary to process my insurance claim.

I hereby assign all my rights to benefits payable by my insurance company to Kim Finnie MSW, CSSW, LCSW and thereby authorize and request my insurance company to pay my benefits directly to Kim Finnie MSW, CSSW, LCSW.

I verify that the above information is correct and accurate and I understand that if I have out-of-network benefits that I will be responsible for the payment when services are rendered and will be reimbursed from the insurance company.

Client Signature:
Date:

**All fields must be completed in order to successfully submit this form