KAREN D. NICHOLS, PH.D.
2320 130th Ave. NE, Suite 110
Bellevue, WA 98005
(425) 889-1240
CLIENT INFORMATION
Name: ______
Home Address: ______
Street
______
CityStateZip Code
Telephone(s): ______(okay to leave messages?)
(Home)
______
(Cell)
Birth Date: ______
Place of Employment: ______
Person who does not live with you to contact in an emergency:
______
NamePhoneRelationship
How were you referred to us? ______
MEDICAL INFORMATION
When were you last examined by a Physician? ______
Name of your Primary Care Physician: ______
City: ______Phone: ______
List any major health problems and/or allergies: ______
______
List any medications you are now taking:
Name Date Began Dose
______
______
______
______
INSURANCE INFORMATION
Confidentiality
If your insurance company utilizes a managed care network for cost containment purposes then your treatment may be subject to a utilization review. This means that your therapist will be required to disclose certain information about your case including diagnosis, symptoms and treatment plan. Some insurance companies reserve the right to audit client’s records.
Medical Necessity
Most managed care networks use the term “medical necessity” to determine authorization for therapy. Medical necessity has to do with improving the client’s level of functioning and alleviating symptoms. It does not include focusing on the source or history of the client’s problems. You have the right to appeal if you disagree with your insurance company’s authorization decision.
Coverage Information
You have the right to decide whether or not to use insurance coverage. If you choose not to use insurance benefits initial here. ______
If you choose to use insurance benefits please complete the following information.
Primary Insurance Company: ______
Phone:______
Subscriber Name: ______Subscriber Date of Birth: ______
Subscriber Address: ______
Subscriber Phone: ______
Subscriber ID # (Please include ALPHA prefix): ______
Group #: ______Employer: ______
Annual Deductible Amount: ______
Copay/Coinsurance Amount: ______
YOUR COPAY IS REQUIRED AT THE TIME OF SERVICE. If your deductible has not been met you are required to pay the full amount for each session until your deductible is satisfied.
I have read and understand the above information. I authorize the release of any medical or treatment information necessary to process the claims.
______
Client Signature Date