Intake Form - Counseling Life Wellness Page 2
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2Janice Motoike, Ph.D., P.L.L.C.
Intake Form
2
RESPONSIBLE BILLING PARTY (ONLY IF DIFFERENT FROM ABOVE)
NAME:
DOB:
ADDRESS:
CITY:
STATE:
ZIP:
TELEPHONE (HOME):
(CELL):
(WORK):
SOCIAL SECURITY #:
RELATIONSHIP TO PATIENT:
EMPLOYER:
OCCUPATION:
PRIMARY CARE PHYSICIAN (PCP) INFORMATION AND RELEASE
PROVIDER NAME:
PHONE:
FAX:
ADDRESS:
CITY:
STATE:
ZIP CODE:
I GIVE MY CONSENT FOR DR. MOTOIKE TO COMMUNICATE WITH MY PCP.
[Includes, but is not limited to, outpatient notification letter and contact for coordination of care]
(Signature)
I DO NOT GIVE CONSENT FOR DR. MOTOIKE TO COMMUNICATE WITH MY PCP.
(Signature)
OTHER PRESCRIBING PROVIDER INFORMATION AND RELEASE (e.g. psychiatrist, endocrinologist, pain specialist):
PROVIDERNAME:
PHONE:
FAX:
ADDRESS:
CITY:
STATE:
ZIP CODE:
I GIVE MY CONSENT FOR DR. MOTOIKE TO COMMUNICATE WITH MY PROVIDER.
[Includes, but is not limited to, outpatient notification letter and contact for coordination of care]
(Signature)
I DO NOT GIVE CONSENT FOR DR. MOTOIKE TO COMMUNICATE WITH MY PROVIDER
(Signature)
If you have other prescribing providers or former behavioral health providers (e.g. former therapists or
psychiatrists), please complete an Authorization Form
ALL 3 SIGNATURES BELOW ARE REQUIRED:
RELEASE OF MEDICAL INFORMATION
I AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESSARY TO PROCESS THIS CLAIM TO MY INSURANCE
COMPANY. I UNDERSTAND THAT THIS RELEASE IS FOR THE PURPOSE OF BILLING AND REIMBURSEMENT.
X
SIGNATURE OF PATIENT OR PRIMARY GUARANTOR
DATE
ASSIGNMENT OF INSURANCE BENEFITS
I AUTHORIZE PAYMENT OF INSURANCE BENEFITS DIRECTLY TO JANICE MOTOIKE, Ph.D. FOR SERVICES PROVIDED I ALSO
ACKNOWLEDGE THAT I AM FINANCIALLY RESPONSIBLE FOR CHARGES NOT COVERED BY THIS ASSIGNMENT.
X
SIGNATURE OF PATIENT OR PRIMARY GUARANTOR
DATE
CONSENT FOR TREATMENT
I HEREBY REQUEST AND CONSENT TO TREATMENT RENDERED BY JANICE MOTOIKE, Ph.D. THIS CONSENT IS FOR VOLUNTARY
TREATMENT ON AN OUTPATIENT BASIS.
X
SIGNATURE OF PATIENT OR GUARDIAN
DATE
Rev 2016 1127
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