Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 Page 8
ADVERTISEMENT
1
2
3
4
5
6
7
8Neal Brugman, Psy.D.
(720) 295-7605
Billing Information
Preferred Method of Payment:
Check
Cash
Credit/Debit/HSA Card
Payment will be made by your preferred method (cash, check, charge); however, a
Credit or Debit Card is kept on file in the event that you do not bring another form of
payment at time of service.
Billing Address:
Check if same as address on ‘Client Information’ page
Address: ___________________________________________________________________
City: ___________________________ State: _______ Zip Code: __________________
Insurance:
Do you have health insurance? Yes No
Health Insurance Provider: ______________________________________________________
Do you plan to seek reimbursement from your insurance for our sessions?*
Yes
No
Unsure
*Please note: I only directly with certain insurance carriers. Please discuss this with me if you would like to obtain
reimbursement from your insurance company for our work together.
I certify the information provided is accurate to the best of my knowledge. I understand that
fees are due at the time of service. I authorize any service fees to be deducted from the form of
payment designated on this form. Should any of the information provided change, I agree to
update my provider as soon as possible.
________________________________________________
_________________
Signature of Client or Legal Guardian
Date
----------------------------------------------------------------------------------------------------------
Credit Card Information:
Account Holder Name: _____________________________________________________________________
Card Type:
Visa
MasterCard Discover Amex
Card Number: ______________________________________________________________________
Expiration Date: ______________
CVV (3 digit code on back of card): _____________
(Please note: once entered into our secure system, your credit card information will be
shredded to ensure security)
The Collaborative Center, LLC
7
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical