Telehealth Insurance Form

Michael Fish, Ph.D. Insurance Form

Telehealth Insurance Form

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Patient’s Name*

Today’s Date

Patient’s Address

Street Address City State / Province / Region ZIP / Postal Code Country

Cell Phone*

Work Phone

Sex

Age

Marital Status

Date of Birth

Referred by

PATIENT’S Employer

Employer’s Address

Street Address City State ZIP Code

INSURED’s Name

INSURED’s Address

Street Address City State ZIP Code

INSURED’s Home Phone

INSURED’s Work Phone

INSURED’s Sex

Age

INSURED’s Marital Status

INSURED’s Date of Birth

INSURED’s Employer

Employer’s Address

Street Address City State ZIP Code

Insurance Information

Primary Insurance

Company Name

Type

ID Number

Policy Group #

Patient

Relation To Insured

Deductible

Met?

Mailing Address

Phone

Secondary Insurance

Company Name

Type

ID Number

Policy Group #

Patient

Relation To Insured

Deductible

Met?

Mailing Address

Phone

(To Be Filled Out By Office)
Insurance Verification

Date

Contact Person

Phone Number

Effective Date of Coverage

Deduct.

Met

Unmet

% covered by Insur

Copay $

# of Visits Allowed Per Year

Max. Benefits per year

Benefits used to date

Precert Required?

Yes

Trmt Plan?

Yes

Psy.Test Cov?

Yes

Lifetime Max

Management Co. Tele.#

Approval #

#of sess

Clms. Mailing Addrs

PATIENT’S NAME

DATE OF BIRTH

I understand that I may withdraw my consent for a specific service or treatment at any time to the extent permitted by law. I must submit my withdrawal in writing.

Signature of PATIENT or GUARDIAN

DATE

To the Client, Parent, or Legal Guardian*

To the Client, Parent, or Legal Guardian*

The financial responsibility for psychological services falls upon the patient. Payment, or co-payment if insurance is involved, for visits is expected at the time of service rendered. If the insurance company is willing to pay for services and the deductible has been met, then the patient is responsible for the co-payment at the time of service. (The above statement is subject to alterations in the case of HMOs and managed care programs). Should a balance remain on an account and a collection agency is employed to collect agreed upon fees, the name of the insured and other identifying information will be provided to the collection agency. Other collection fees may be charged by the collection agency. It is also expected that the patient know the limits of the insurance policy. Should the insurance company fail to pay, the patient or legal representative is financially responsible for payment. A diagnosis will need to be provided to your insurance company in order for the office to be paid.

Note that if Dr. Fish must be involved with any litigation because of services provided to the patient or affiliated parties: 1) Charges will be higher than the office fee. 2) Special arrangements for payment must be made in advance of involvement. 3) Out-of-office services, including court appearances, depositions, telephone interviews, consultations with other professionals, psychological testing, report writing, and travel time will be charged to you or your designated responsible party.

Dr. Fish’s hours are made by appointment only. Because the appointment is reserved for you, it is necessary to charge the patient for appointments which are not canceled 24 hours in advance, unless in fact they are caused by circumstances which both parties define as an emergency. Failure to provide a 24 hour notice of cancellation generally means that some other person is not able to use that appointment time. Insurance companies cannot be billed for these lost appointment hours and, therefore, it will be the patient's responsibility to pay the full hourly fee.

I have read the above material and agree to these terms.

SIGNATURE*

DATE*