Fillable Financial Agreement Form printable pdf download

Financial Agreement Form

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Complete Financial Agreement Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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FINANCIAL AGREEMENT

Client Information

Last Name: ___________________________ First Name: _______________________ Middle Initial: ______

Social Security Number: _______________________________

Date of Birth: _________________________

Address: _____________________________________ City: ______________ State: ______Zip: _____________

Home Phone: __________________ Alternate Phone (specify if work or cell): _______________________

Employment:

Employed

Full-Time Student

Gender:

Male

Part-Time Student

Other (specify) _____________

Female

Name of Employer: _____________________________________ Employer Phone: _____________________

Employer Address: ____________________________ City: ____________ State: ______Zip: _____________

B. Insurance Information

Name of Person Responsible for Bill: ____________________________________ Date of Birth: __________

Relationship to the client: __________________________ Social Security Number: ____________________

Address (if different): ___________________________________________________________________________

Home Phone: _____________________ Alternate Phone (specify if work or cell): ____________________

Name of Employer: ______________________________________Employer Phone: _____________________

Employer Address: ______________________ City: ____________ State: ______Zip: _____________

Primary Insurance Information

Name of Insurance Company: _____________________________ Policy #:____________________________

Subscriber’s Name: ____________________________ Subscriber’s SSN: _____________________________

Client’s Relationship to Subscriber: ____________________________ Co-pay amount: ________________

Insurance Company Phone: ____________________________ Effective Date: _______________________

Do you have a calendar year deductible? Yes ____ No ____If so, how much have you met? ______

Financial Agreement V-3

Property of Therapeutic Partners, PLLC Not to be reproduced without permission

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Financial Agreement Form

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