Insurance Information

Melissa McCreery, PhD INSURANCE AND BILLING

1201 11th St., Ste 200B Bellingham, WA 98225

360.671.8520 / fax 360.715.3657

Name

Person responsible for copayments, coinsurance, deductibles, and/or payment in full:

Name:

Relationship to client: DOB:

Employer:
SSN: Phone:

Subscriber's Address:

Please provide insurance card(s) at first appointment

Primary Insurance Company:

Subscriber's Name: DOB:

SSN: Employer:

Subscriber's Address:

Secondary Insurance Company

(Please furnish copy of front and back of insurance card or billing address)

Subscriber's Name:

DOB:

SSN: Employer:

Subscriber's Address:

Payment and Insurance billing:
I, the undersigned, authorize the release of any medical or other information necessary to process this claim through the insurance company previously noted. I authorize payment to Dr. McCreery for services rendered as stated on claims submitted by her to my insurance company.

I also understand that it is my responsibility to reimburse Dr. McCreery for any services provided on my behalf. In the event that my insurance does not cover costs for services rendered or I do not have insurance coverage at this time, I agree to pay any and all costs of psychotherapy. Costs may include any missed appointments, fees for written reports, phone calls on my behalf, or any other costs of providing services on my behalf.

Signature:

___________________________________________________________

For your information, your insurance company may require Dr. McCreery to provide information about your treatment in order to to process your claim(s). You may make arrangements to pay for psychotherapy privately to avoid confidential information being released to your insurance company. Please discuss these options and the option of private payment with Dr. McCreery.