P.O. Box 2623 Mercerville, NJ 08619
P: 609-638-7560 /F: 609-581-4762
Date of Birth:
Social Security #
Your Best Contact Number (Where a message can be left):
Person Responsible for Bill: (if same state "Same")
Address (If different than above):
Is this patient covered by insurance?
Co-payment Amount For Behavioral Health/Mental Health/Substance Abuse Treatment:
Deductible Amount For Behavioral Health/Mental Health/Substance Abuse Treatment:
Patient's relationship for Subscriber: SelfSpouseChildOther Secondary insurance(If applicable):
Social Security #:
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Champion Psychological Services, LLC. I understand that I am financially responsible for any balance. I also authorize Champion Psychological Services, LLC, or the insurance company to release any information required to process my claims.
Patient/Guardian Name Printed and Date
Patient/Guardian Signature Printed and Date