Registration Form
Flourish Counseling, PLLC
Date____________________ DX Code___________________________
Therapist Mary C. Zinkel
Patient Information
Patient Name (Print)___________________________________________ Date of Birth ______________________________ Last Name First Name Initial
Street Address_______________________________________________________ Home Phone ______________________________ City_____________________________________________________State_________ZIP____________ Work Phone___________ Soc. Sec. #__________________________Emergency Contact_______________ Emerg Phone ______________________________ Sex: Female Male Age__________ Marital Status: Single Married Partnered Divorced Separated Widowed Other
Employer ___________________________________ Occupation_______________________________________________________ Referred by________________________________May we acknowledge this referral?_______________________________________
Primary Insurance
Primary Insurance Company____________________________________________Phone ______________________________
Ins Claims Address___________________________City___________________________State_________Zip____________________
Policy/ID #_____________________________________________Group/Plan #____________________________________________
Policy Holder Information: (if the patient is not the employee/policy holder)
Name__________________________________________________________Relationship _________________________________ Last name First Name Initial
Address______________________________________________________City___________________State______Zip_____________Date of Birth_______________ Soc. Sec#________________________ Employer________________________________________
Secondary Insurance
Secondary Insurance Company________________________________________________________________________ Phone ______________________________
Ins Claims Address_________________________________________City___________________________State_________Zip______________
Policy/ID #_____________________________________________Group/Plan #____________________________________________
Policy Holder Information: (if the patient is not the employee/policy holder)
Name_______________________________________________________________________Relationship ______________________ Last name First Name Initial
Address______________________________________________________City___________________State______Zip_____________Date of Birth_______________ Soc. Sec#___________________________________Employer_____________________________
Responsible Party (Where should the patient=s portion of the bill be sent, if not to the patient?)
Name ______________________________________________________________Relationship ______________________________
Address______________________________________________________________Phone __________________________________
Assignment and Release
I the undersigned, certify that I (or my dependent) have insurance coverage as noted above and assign directly to the healthcare provider listed at the top of this form all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the healthcare provider to release all information necessary to secure the payment of benefits and to mail patient statements. I authorize the use of this signature on all insurance submissions.
_________________________________________________________________ ___________________________ _______________________________ Responsible Party Signature Relationship To Patient Date