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.
Please upload pictures of the front and back of your insurance card if you wish to use insurance.
Insurance Plan Type: (EAP Not Accepted)"
Other (Specify below)
Policy Holder Date of Birth
Name of Psychiatrist if you have one: (Optional)
Financial agreement summary: I agree to pay invoices within the first week of the month. For in-network insurance, Dr. Klein will submit claims directly and I will owe my share of costs according to my plan. It is my responsibility to know if I have a deductible, and what my copays are in advance so as to plan for my own expenses. If I am using out-of-network benefits, Dr. Klein may bill on my behalf as a courtesy to me, and I will owe him the full fee directly regardless of how insurance reimburses me. I know that two business days are needed for cancellations, and I agree to pay my full fee otherwise. I know that insurance does not pay for missed sessions. I have read and agree to the full financial policies on https://drkleinpsychology.com.
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