Insurance

Client Name*
First Last
Date*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Are you using your EAP benefits?
EAP Auth Number
Enter your EAP Name & Authorization number here. If you don't have it, please bring it to your first session.
Insurance Card*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 2.
Please upload the front and back of your insurance card
Primary Insurance Carrier
Insurance ID Number
Name of Insured
Insured Date of Birth
MM slash DD slash YYYY
SSN of Insured
Do you have a second insurance?
Insurance Card
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 2.
Please upload the front and back of your insurance card
Secondary Insurance Carrier
Secondary Insurance ID Number
Secondary Insurance Name of Insured
DOB of Secondary Insurance
MM slash DD slash YYYY
Secondary Insurance SSN
Consent*
I agree to the payment policy.
Although this office will process claims by billing insurance companies, I understand that payment for insurance deductibles and co-pays are my responsibility. We do not impose any charge for no-show/late cancellation appointments, nor do we use collection agencies for outstanding late payments. By signing below, I give permission for submission to my insurance company.
Consent*
I agree with the billing policy
In signing this document, I acknowledge and consent to John G. Kuna, Psy.D., Pennsylvania State Licensed Psychologist (License # PS016759), in supervising our therapy sessions.

I understand that Dr. Kuna will sign the claims submitted to the insurance company as the Supervising Psychologist. As such, I accept full responsibility for the charges incurred by my therapy sessions.
Name*
First Last
Signature*
Date*
MM slash DD slash YYYY