New Patient Registration Form

Ingrid Raab, Psy. D.
572 Washington Street
Wellesley, Ma 02482
781.237.0909
www.DrRaab.com
NEW PATIENT REGISTRATION FORM
PERSONAL INFORMATION
HEALTH INSURANCE INFORMATION:
NAME:_______________________
INSURANCE CO. ____________________
ADDRESS:____________________
ID NO: _____________________________
_______________________
SUBSCRIBER: ______________________
________________________
SUBSCRIBER D-O-B: ________________
PHONE #s. ___________________(H)
SUBSCRIBER SOC.SEC. #:
_______________________(W)
___________________________________
_______________________(Cell)
EMPLOYER: _______________________
PATIENT SOC SEC NO.
RELATIONSHIP TO PATIENT: ________
_________________________________
PRE-AUTHORIZATION#:____________
AGE: _______ D-O-B: ______________
C0-PAY: __________________________
MARITAL STATUS: S M DIV SEP W, E-MAIL:________________________________
REFERRED BY: ________________________________________________________
PRIMARY CARE PHYSICIAN: ___________________________________________
PSYCHO-PHARMACOLOGIST: ___________________________________________
MEDICATIONS: ________________________________________________________
_______________________________________________________________________
AUTHORIZATION TO PAY INSURANCE BENEFITS: I hereby direct my insurance
carrier to make payments directly to Dr. Ingrid Raab for health insurance benefits otherwise payable to
me, but not to exceed Dr. Raab’s regular charges. I understand that I am financially responsible for charges
not covered by this authorization (including insurance co-payments and deductibles that are due at the
time of service). I also understand that it is my responsibility to contact my insurance company to obtain
any necessary pre-certification of treatment as required by my insurance plan (e.g. Calling an 800 number
prior to or on the day of my first appointment). This assignment of benefits shall be valid for the duration
of my treatment with Dr. Raab and one year thereafter.
Date: __________
Signature of Patient/Guardian: _____________________________
AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize Dr. Ingrid Raab to release
billing and medical information to my insurance company necessary to process claims for services
rendered to me by Dr.Raab. This authorization is limited to the release of only that information necessary
to substantiate and process health insurance claims and excludes such confidential information which by
law may only be released by specific consent.
Date: __________
Signature of Patient/Guardian: _____________________________