By engaging in services with TMG you are agreeing to assume the full financial responsibility for services offered for all portions that is not covered by your insurance company. It is the patients responsibility to ensure they are aware of what benefits are covered by their insurance company. Annually we review fees and review clients insurance coverage, patients will be notified of any fee increases associated with services. Please complete the following and return prior to your initial session. (Please upload copies of your Insurance card (front and back), Identification (front and back).Insurance CardMax. file size: 32 MB.IdentificationMax. file size: 32 MB.Client's Name Date of Birth MM slash DD slash YYYY AgeAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneWork PhoneEmail Marital Status S M D W Gender Employer/School Occupation/Year in School Race White/Caucasian African-Am. Asian Latino/Hispanic Native Am. Multiracial Other Spirituality Importance to You Parent or Guardian (if under 18) Who referred you?Name PhoneMay your therapist acknowledge the referral? Yes No I would like to be placed on the Care and Counseling mailing list to receive newsletters and other center information.Emergency Contact Spouse Partner Other Name Relationship Home PhoneCell PhoneWork PhonePermission to Call Yes No Restrictions Secondary Client’s Name Date of Birth MM slash DD slash YYYY AgeEmail Marital Status S M D W Gender Race White/Caucasian African-Am. Asian Latino/Hispanic Native Am. Multiracial Other Party responsible for payment Self Other If other, please specify relationship. Insurance (The office will need a copy of both sides of your insurance card.)Primary Insurance PhoneInsured Name DOB MM slash DD slash YYYY SS#ID#Group #Employer **Authorization # (if required by insurance company): **If I fail to obtain authorization, I am responsible for payment to TMG for the denied session.Secondary Insurance PhoneInsured Name DOB MM slash DD slash YYYY SS#ID#Group #Employer**Authorization # (if required by insurance company): **If I fail to obtain authorization, I am responsible for payment to TMG for the denied session. (Please upload copies of your Insurance card (front and back), Identification (front and back).Insurance CardMax. file size: 32 MB.IdentificationMax. file size: 32 MB. I am responsible for obtaining all authorizations and for all charges not covered. I understand that I am responsible for charges not covered or reimbursed by the above agents. I agree, in the event of non-payment, to assume the costs of interest, collection and legal action (if required and waive confidentiality for this purpose). My therapist may discuss accommodations in special circumstances (i.e. video therapy, phone sessions); it is my responsibility to determine insurance coverage for these sessions or to cover the cost of the service at the agreed-upon rates. My therapist may discuss accommodations in special circumstances (i.e. video therapy, phone sessions); it is my responsibility to determine insurance coverage for these sessions or to cover the cost of the service at the agreed-upon rates. I authorize TMG staff to communicate with my insurance company for the purpose of claim verification and authorization for services, including a diagnosis code, and for my insurance carrier to release information regarding my coverage to TMG. I authorize the release of any medical or other information necessary to process this claim. My right to payment for all services are hereby assigned to TMG. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made directly to me or my representative, I will endorse such payments to TMG. By signing I indicate that I have been notified of my responsibilities for all fees, co-pay/session rate, late cancellation (<24 hours’ notice) and no shows I may be responsible for, and that I agree to pay those promptly. I have read the above statements and accept the terms. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.Client Signature or Authorized Persons Signature Date MM slash DD slash YYYY Time Responsible Party Signature Relationship Date MM slash DD slash YYYY Time HEALTH HISTORY1. Name Date of Birth MM slash DD slash YYYY Occupation In Case of Emergency Contact Phone NumberRelationship Children and Ages 2. Primary Care Physician Phone Number3. Serious Medical Illness/Accidents (Identify and give dates) 4. Are you currently on any medications? Yes No If yes, please list.Any past medications?5. Surgeries or operations (Identify and give dates)6. Any hospitalizations? Yes No If yes, when and for what reason7. Have you ever been treated for depression/anxiety? Yes No If yes, by whom? Title Internist OB/Gyne Psychiatrist Please list any medications prescribed. 8. Have you had any previous counseling? Yes No If yes, with whom and when? 9. Are you or have you been in the care of a psychiatrist? Yes No If yes, with whom and when? 10. Have you ever been treated for alcohol or drug abuse? Yes No If yes, when and where? 11. Have you been the victim of physical or sexual abuse? Yes No 12. Do you have suicidal thoughts? Yes No 13. Have you had a suicidal attempt? Yes No If yes, when? 14. Do you or have you had an eating disorder? Yes No 15. Do you have a history of infectious diseases? Yes No If yes, please describe. 16. Do you have any allergies? Yes No If yes, please describe any adverse reactions. 17. Is there past or present nicotine use? Yes No DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.Client Signature Date MM slash DD slash YYYY Legal Guardian Signature Date MM slash DD slash YYYY
