Insurance Form

Patient Name:

Primary Insurance

None:

Insurance Name:

ID:

Group No.:

Group Name/Employer:

Insured Name:

Insured Address:

City/State/Zip:

Insured Relationship to Patient:

DOB:

SSN:

Secondary Insurance

Insurance Name:

ID:

Group No.:

Group Name/Employer:

Insured Name:

Insured Address:

City/State/Zip:

Insured Relationship to Patient:

DOB:

SSN:

Photo of Front and Back of Insurance Card

Front of Card:

Back of Card:

Photo of Front and Back of Secondary Insurance Card

Front of Card:

Back of Card:

Statesboro Psychiatric Associates does not participate with Medicare, Tricare or Medicaid. I understand that if covered by any of these entities that I must sign a waiver in order to receive treatment at this office. I understand that the waiver states that I may not file claims on my behalf to Medicare, Tricare or Medjcaid for services rendered by Statesboro Psychiatric Associates, and that I am fully responsible for payment of these services.

Signature of Patient/Responsible Party:

Date:

I understand that it is my responsibility to alert Statesboro Psychiatric Associates to any and all changes in my insurance coverage, and that failure to provide these updates in a timely fashion may result in denial of claims by my new insurance company, and that I will be fully responsible for payment of these services.

Signature of Patient/Responsible Party:

Date:

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