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Bonnie R. Saks M.D. & Associates, LLC
Bonnie R. Saks M.D. & Associates, LLC
REGISTRATION FORM
(Please Print)
Today’s
Date _____/_____/_____
Provider_______________________________
PATIENT INFORMATION
Patient’s Last Name
First
Middle
q Mr.
q Mrs.
q Miss
q Ms.
Marital Status (Circle One)
Single / Mar
/ Div / Sep / Wid
Is this your legal name?
If not, what is your legal name?
(Preferred
Name)
Birth Date
Age
Sex
q Yes
q No
/
/
q M
q F
Street Address
City
State
ZIP Code
Social Security
Home Phone No.
( )
P.O. Box
City
State
ZIP Code
Employer
Work Phone
No.
Mobile Phone No.
( )
( )
q Dr.
q Insurance Plan
q Hospital
q Family
q Friend
q Close to Home/Work
q Phone Book
q Other
Other Family Members Seen Here
Can messages be left
on phone numbers listed above (please check one box) □ Yes □ No
INSURANCE INFORMATION
(please give your insurance card to the receptionist)
Person Responsible for Bill
Birth Date
Address (if different)
Home
Phone No.
/
/
(
)
Is this person a patient here?
q Yes
q No
Occupation
Employer
Employer
Phone No.
(
)
Is this patient covered by insurance?
q Yes
q No
Please indicate primary insurance
q Aetna
q BC/ BS
q Cigna
q Humana
q Medicare
q Tricare, Standard or Prime?
q United Healthcare
q Value Options
q Other
Subscriber’s Name
Subscriber’s S.S. #
Birth Date
Group #
Policy
#
Co-Payment
/ /
$
Patient’s Relationship
to Subscriber
q
Self
q
Spouse
q Child
q Other
Name of Secondary Insurance (if applicable)
Subscriber’s
Name
Group
#
Policy #
Patient’s Relationship to Subscriber
q Self
q Spouse
q Child
q Other
IN CASE OF
EMERGENCY
Name of Local Friend or Relative (not living at same
address)
Relationship to Patient
Home Phone No.
Work Phone No.
( )
(
)
The above information is
true to the best of my knowledge. I give my consent for Bonnie Saks & Associates to provide treatment
using psychotherapy and or medication. I authorize my insurance benefits be paid directly to the
physician. I also authorize Bonnie Saks & Assoc. or insurance company to release any information required
to process my claims.
X
PATIENT/GUARDIAN SIGNATURE
DATE
Bonnie R. Saks M.D. & Associates, LLC
REGISTRATION FORM
(Please Print)
Today’s
Date _____/_____/_____
Provider_______________________________
PATIENT INFORMATION
Patient’s Last Name
First
Middle
q Mr.
q Mrs.
q Miss
q Ms.
Marital Status (Circle One)
Single / Mar
/ Div / Sep / Wid
Is this your legal name?
If not, what is your legal name?
(Preferred
Name)
Birth Date
Age
Sex
q Yes
q No
/
/
q M
q F
Street Address
City
State
ZIP Code
Social Security
Home Phone No.
( )
P.O. Box
City
State
ZIP Code
Employer
Work Phone
No.
Mobile Phone No.
( )
( )
q Dr.
q Insurance Plan
q Hospital
q Family
q Friend
q Close to Home/Work
q Phone Book
q Other
Other Family Members Seen Here
Can messages be left
on phone numbers listed above (please check one box) □ Yes □ No
INSURANCE INFORMATION
(please give your insurance card to the receptionist)
Person Responsible for Bill
Birth Date
Address (if different)
Home
Phone No.
/
/
(
)
Is this person a patient here?
q Yes
q No
Occupation
Employer
Employer
Phone No.
(
)
Is this patient covered by insurance?
q Yes
q No
Please indicate primary insurance
q Aetna
q BC/ BS
q Cigna
q Humana
q Medicare
q Tricare, Standard or Prime?
q United Healthcare
q Value Options
q Other
Subscriber’s Name
Subscriber’s S.S. #
Birth Date
Group #
Policy
#
Co-Payment
/ /
$
Patient’s Relationship
to Subscriber
q
Self
q
Spouse
q Child
q Other
Name of Secondary Insurance (if applicable)
Subscriber’s
Name
Group
#
Policy #
Patient’s Relationship to Subscriber
q Self
q Spouse
q Child
q Other
IN CASE OF
EMERGENCY
Name of Local Friend or Relative (not living at same
address)
Relationship to Patient
Home Phone No.
Work Phone No.
( )
(
)
The above information is
true to the best of my knowledge. I give my consent for Bonnie Saks & Associates to provide treatment
using psychotherapy and or medication. I authorize my insurance benefits be paid directly to the
physician. I also authorize Bonnie Saks & Assoc. or insurance company to release any information required
to process my claims.
X
PATIENT/GUARDIAN SIGNATURE
DATE
Today’s Date _____/_____/_____ | Provider_______________________________ | |||||||||||||||||||||||||||||||||||||||||||||||||||||
PATIENT INFORMATION | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patient’s Last Name | First | Middle | q Mr. q Mrs. | q Miss q Ms. | Marital Status (Circle One) | |||||||||||||||||||||||||||||||||||||||||||||||||
Single / Mar / Div / Sep / Wid | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is this your legal name? | If not, what is your legal name? | (Preferred Name) | Birth Date | Age | Sex | |||||||||||||||||||||||||||||||||||||||||||||||||
q Yes | q No | / / | q M | q F | ||||||||||||||||||||||||||||||||||||||||||||||||||
Street Address | City | State | ZIP Code | Social Security | Home Phone No. | |||||||||||||||||||||||||||||||||||||||||||||||||
( ) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
P.O. Box | City | State | ZIP Code | |||||||||||||||||||||||||||||||||||||||||||||||||||
Employer | Work Phone No. | Mobile Phone No. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
( ) | ( ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
q Dr. | q Insurance Plan | q Hospital | ||||||||||||||||||||||||||||||||||||||||||||||||||||
q Family | q Friend | q Close to Home/Work | q Phone Book | q Other | ||||||||||||||||||||||||||||||||||||||||||||||||||
Other Family Members Seen Here | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Can messages be left on phone numbers listed above (please check one box) □ Yes □ No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
INSURANCE INFORMATION | (please give your insurance card to the receptionist) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Person Responsible for Bill | Birth Date | Address (if different) | Home Phone No. | |||||||||||||||||||||||||||||||||||||||||||||||||||
/ / | ( ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Is this person a patient here? | q Yes | q No | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Occupation | Employer | Employer Phone No. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
( ) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is this patient covered by insurance? | q Yes | q No | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Please indicate primary insurance | q Aetna | q BC/ BS | q Cigna | q Humana | q Medicare | |||||||||||||||||||||||||||||||||||||||||||||||||
q Tricare, Standard or Prime? | q United Healthcare | q Value Options | q Other | |||||||||||||||||||||||||||||||||||||||||||||||||||
Subscriber’s Name | Subscriber’s S.S. # | Birth Date | Group # | Policy # | Co-Payment | |||||||||||||||||||||||||||||||||||||||||||||||||
/ / | $ | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Patient’s Relationship to Subscriber | q Self | q Spouse | q Child | q Other | ||||||||||||||||||||||||||||||||||||||||||||||||||
Name of Secondary Insurance (if applicable) | Subscriber’s Name | Group # | Policy # | |||||||||||||||||||||||||||||||||||||||||||||||||||
Patient’s Relationship to Subscriber | q Self | q Spouse | q Child | q Other | ||||||||||||||||||||||||||||||||||||||||||||||||||
IN CASE OF EMERGENCY | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Name of Local Friend or Relative (not living at same address) | Relationship to Patient | Home Phone No. | Work Phone No. | |||||||||||||||||||||||||||||||||||||||||||||||||||
( ) | ( ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
The above information is true to the best of my knowledge. I give my consent for Bonnie Saks & Associates to provide treatment using psychotherapy and or medication. I authorize my insurance benefits be paid directly to the physician. I also authorize Bonnie Saks & Assoc. or insurance company to release any information required to process my claims. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
X | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
PATIENT/GUARDIAN SIGNATURE | DATE | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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