Today's Date:
Patient's Name:
Marital Status:
Gender:MaleFemale
Date of Birth:
Social Security #
Email Address:
Home Address:
Home Phone#:
Cell Phone#:
Occupation:
Employer:
Employer Phone#:
Your Best Contact Number (Where a message can be left):

Insurance Information

Person Responsible for Bill: (if same state "Same")
Birth Date:
Address (If different than above):
Home Phone#:
Occupation:
Employer:
Employer Address:
Employer Phone#:
Is this patient covered by insurance?
Primary Insurance:
Subscriber's Name:
Subscriber's S.S.#:
Birth Date:
Group:#
Policy #:
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):
Subscriber's Name:
Birth Date:
Social Security #:
Group #:
Policy #:

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

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