IF PRESENTLY ATTENDING SCHOOL, PLEASE STATE
STATUS OF CURRENT HEALTH:
CURRENT MEDICATIONS: (Including Dosage, If NONE state so)
List medication, strength (mg) and dosage for each
If you will not be using
insurance, please complete the below Monthly Budget Information:
MONTHLY HOUSEHOLD & LIVING EXPENSES
List any other bills not listed, and specify frequency (monthly, weekly, etc.)
INSURANCE BENEFITS INFORMATION & PATIENT RESPONSIBILITIES
*****PLEASE MAKE SURE THE BELOW INFORMATION IS COMPLETE & SIGNED*****
I hereby assign the insurance benefits to which I may be entitled to the Karen Horney Clinic, Inc. and I authorize payment of these to be made directly to said clinic. I authorize the Karen Horney Clinic, Inc. to communicate any pertinent data to my insurance company regarding this assignment. I also understand that if for any reason my insurance does not cover my expenses that I will be held responsible for prompt payment of any monies due:
In-Network Insurances Please be prepared to pay before each appointment. You are responsible for any deductible, copay and/or coinsurance indicated by your insurance plan, including the full balance due to termination of coverage. You will be responsible for “non-covered” services as deemed by your carriers. NOTE: Some insurance carriers may require that you notify them of your visit with us. Please contact them to avoid additional financial responsibility.
Out-of-Network Insurances Please be prepared to pay before each appointment. You are responsible for 100% of the fee.