Patient Information – Luzio & Associates Behavioral Services, Inc.

Luzio & Associates Behavioral Services, Inc.
PATIENT INFORMATION

Last Name

First Name

Middle Initial

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Please upload a copy of your Photo ID. (ADULT ONLY)

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Street Address

City

State

Zip Code

Primary Phone Number

Secondary Phone Number

Date of Birth

Gender

Social Security Number

Employer

Student Status:

Non-Student Full-Time Part-Time

Parent/Guardian (if minor)

Date of Birth

Social Security Number

Employer

Primary Phone Number

Secondary Phone Number

Insurance Information

Please upload a copy of your Insurance Card (FRONT)

Please upload a copy of your Insurance Card (BACK)

Policy Holder

Social Security Number

DOB

Address

Insurance Company

Insurance Company Phone Number

Member ID

Group Number

Patient's Relationship to policyholder

Self Spouse Dependent

Secondary Insurance Company

Member ID

Group Number

Policy Holder

Social Security Number

DOB

In the event that it becomes necessary for us to file insurance on your behalf, I authorize Luzio & Associates Behavioral Services, Inc. to disclose information to insurance carriers concerning the diagnosis and treatments for myself and/or my dependents, and I hereby assign all third party payments to Luzio & Associates Behavioral Services Inc. for services rendered to the aforesaid persons. I understand that I am financially responsible for the charges. Payment is expected for services when rendered unless other arrangements have been made with this office.

I/We agree to pay directly to Luzio & Associates Behavioral Services Inc. and/or said doctors the charges incurred for services received at their established rates. I/We will pay all attorney fees and court costs incurred by Luzio & Associates Behavioral Services Inc. or said said collecting any unpaid balances for services I/the patient received.

Signature of Patient or Legal Guardian

Date

Children/Sibling

Name

Age

Name

Age

Name

Age

Name

Age

Name

Age

Name

Age

Who referred you?

Are you on medication now?

If so, what type?

Family Physician

Have you previously had professional help?

If yes, name of doctor/therapist

Emergency Contact

Relationship

Are we authorized to contact them?

Phone Numbers

CONSENT FOR MENTAL HEALTH SERVICES

I, the undersigned, agree and consent to participate in mental health services offered and provided by a provider at Luzio & Associates Behavioral Services, Inc.

✓ a Mental Health Services Provider of Psychology as defined by Indiana law.
OR
✓ a Mental Health Services Provider who is supervised by a Psychologist as defined by Indiana law.

(a) the scope of the provider's license, certification, and training;
(b) the scope of license, certification, and training of those mental health providers directly supervising the services received by the patient.

Patient's Name

Signature

Date

Relationship to Patient

Witness Signature

Luzio & Associates Behavioral Services, Inc.PATIENT INFORMATION

Luzio & Associates Behavioral Services, Inc.
PATIENT INFORMATION