Appointment Request, Information, Informed Consent
Patient’s Last Name
Date of Birth
Type your Scheduling Request Here
Name of Parent or Legal Guardian (if applicable)
Relationship to Patient
Emergency Contact Name & Phone Number
Email Address ( if it’s ok that I contact you this way)
Cell Phone Number
Other Phone Number
I prefer not to use insurance, and I am not going to inform Dr. Klein Psychological Services, inc that I have insurance. I wish not to have a third party involved in my healthcare decisions and I want my health information to be entirely private. I realize that if Dr. Klein happens to be contracted on my insurance panel I cannot receive reimbursement for expenses.
I prefer to upload pictures of the front and back of my insurance card instead of filling out the insurance IDs below.
Insurance Plan Type: (EAP Not Accepted)"
Other (Specify below)
Name of Primary Insurance Company
Insurance Plan Name
Insurance Company Address (See back of card)
Insurance Company’s Phone # (See back of card)
Name of Policy Holder (If not same as patient)
Policy Holder Date of Birth
Name of Psychiatrist if you have one: (Optional)
I have downloaded and read the Office Policies and Informed Consent, the Financial Agreement, and the HIPAA Notice documents available on https://www.drkleinpsychology.com and I agree and consent to all policies. I have had the opportunity to ask questions about all policies. Dr. Klein may use any insurance billing company to submit my information if I am using insurance and that I will receive either post or email billing at the addresses provided above containing my statements.
Patient(s) or Legal Guardian’s Signature