P.O. Box 2623 Mercerville, NJ 08619
P: 609-638-7560 /F: 609-581-4762
drhodges@championpsychsvcs.com
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):
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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