Client Information Sheet - Dr. Tanya Mesirow

Tanya Mesirow, Psy.D.
Clinical Psychologist
PSY17044
Please fill out completely - If incomplete, claims will not process & insured will be responsible for charges.
PATIENT INFORMATION
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number
Sex
- Male
- Female
Marital Status
Address
Street Address City State ZIP Code
Home Phone*
Cell Phone
Employer Name
Work Number
INSURANCE INFORMATION
Primary Insurance
Type of Plan
Insurance Address
Street Address Address Line 2 City State ZIP Code
Insured Name
First Last
Relation to Patient
Insured Date of Birth
MM slash DD slash YYYY
Insured Social Security Number
ID #
Group #
Effective Date
MM slash DD slash YYYY
Insurance Phone Number
Employer
Do you have a secondary insurance?
- Yes
- No
Secondary Insurance
Type of Plan
Insurance Address
Street Address Address Line 2 City State ZIP Code
Insured Name
First Last
Relation to Patient
Insured Date of Birth
MM slash DD slash YYYY
Insured Social Security Number
ID #
Group #
Effective Date
MM slash DD slash YYYY
Insurance Phone Number
Employer
I, the undersigned, certify that I (or my dependent) have insurance coverage with the company/companies stated above and assign directly to patient above all insurance benefits, if any, otherwise payable by me for services rendered. I understand that I am financially responsible for all charges whether paid by the insurance or not. I hereby authorize the doctor/clinician to release all information necessary to secure the payment of benefit. I authorize the use of this signature on all insurance submissions.
Relationship
Date Signed
MM slash DD slash YYYY
Note: Please contact C.D. Billing Services for all billing and payment questions.

Telephone # (650) 344-6961 Fax # (650) 344-6604
Signature
PATIENT FINANCIAL AGREEMENT
I understand that my records are confidential and will not be released to outside individuals of agencies without written consent. However certain information may be released without my authorization under the following circumstances:
1. In the event of a medical emergency.
2. If there is evidence of child abuse, dependent or elder abuse.
3. When a hazard to the public requires disclosure.
4. When there is an indication that I will likely harm myself.
TELEPHONE CONSULTATIONS: I understand that telephone consultations are not covered by Medicare and other health plans. Therefore, I understand that telephone contacts beyond appointment scheduling may result in a charge equivalent of $120.00 per hour for the duration of call.

CANCELLATIONS: Appointments are regarded as a contract for the exclusive use of the doctor’s time. I understand that regular charges may be applied to missed appointments without 48 hour advance cancellation notice. I understand that my insurance carrier will not pay for my absence and I may be responsible for these charges.
Date
MM slash DD slash YYYY
Signature

Tanya Mesirow, Psy.D. Clinical Psychologist PSY17044

PATIENT INFORMATION

INSURANCE INFORMATION

PATIENT FINANCIAL AGREEMENT

Tanya Mesirow, Psy.D.
Clinical Psychologist
PSY17044