Patient Registration Form Patient's Name * First Name Last Name Social Security # * Date of Birth * MM DD YYYY Sex * Male Female Other Home Address: * Please enter your full address, including state and zip code. Home Phone (###) ### #### Work Phone (###) ### #### Cell Phone * (###) ### #### Marital Status * Married Divorced Single Widowed Occupation * Patient Employed by * Insured Name * Insured DOB * MM DD YYYY Insured SSN * Insurance ID # Do you have medical insurance? * Yes No If so, name of the primary insurance: Emergency Contact * Name, phone number, and email address Assignment & Release I, the undersigned certify that I (or my dependent) have insurance coverage with And assign directly to Rivkah Kaufman, LMHC, all insurance benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for services that are not covered by insurance, and all charges whether or not paid by insurance. I hereby authorize the provider to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Patient’s or Guardian’s Initials * Relationship * Date * MM DD YYYY Thank you!
