Insurance - Dr. John G Kuna and Associates

Client Name*
First Last
Date*
Date of Birth*
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: jpeg, 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
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
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*