New Client Information

Please use the form below to submit your new client information (Note: Fields marked with * are required):

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Client name: *

Date of birth:

Social security #

Telephone:

Email address:

Insurance company:

ID number:

Group number:

Secondary insurance company, ID number, and group number:

Client address:

Subscriber name, DOB, and SS#:

Current Physician name/telephone#:

Current diagnosis, reason for seeking treatment, and previous treatment history:

Credit card number, name on card, cardholder zip code, expiration date, and CVV#:

Patient/Guardian Name and Date (will count as electronic signature and consent to Cancellation, Payment, and Re-scheduling Policy below): *

Captcha (spam protection code) *

*

Cancellation, Payment, Re-scheduling Policy: I hereby certify that the subscriber listed in this document has active behavioral health/medical coverage with the above-named insurer. My electronic signature above is providing express consent to assign all insurance benefits from this company, in relationship to this treatment, otherwise payable to me, directly to Riverview Psychological Services, P.C. I further understand that if the subscriber's behavioral health/medical coverage is denied or terminated during the course of treatment, I am completely responsible for all payments of any services rendered. This includes co-payments and deductibles that are not reimbursed through the subscriber's insurance policy. I hereby authorize Riverview Psychological Services, P.C. to release all information necessary to secure the payment of benefits. I authorize the use of the signature above on all insurance submissions, whether manually or electronically. In regard to the cancellation/no show policy, I understand that 48 hour notice is required to change or cancel an appointment. I understand that a $50.00 "time reserved" charge may be applied for cancellations/no shows that occur within the 48 hour window. In addition, a copy of our Notice of Privacy Practices "HIPPA form" has been made available to me (see Patient Forms section on our website). I give consent for treatment deemed necessary or beneficial by my clinician for my well-being. I understand that my credit card may be charged for late cancellations or no-shows.

Note: Fields marked with * are required

New Client Information

Contact and Appointments

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