Client Information for Jeffrey R. Petra, Ph.D

CLIENT INFORMATION FOR JEFFREY R. PETRA, PH.D.: Please provide information/circle responses as appropriate. Please give legal name (s) with middle name. Please note other names in parentheses.

Client Name: ______Gender: M F Birthdate:______Address: ______H. Phone ( ) ______W. Phone( ) ______Employer/School:______C. Phone ( )______E-mail Address: ______School Phone ( ) ______SSN:______Spouse/Partner: ______

Parent 1: ______Gender: M F Birthdate:______Parent 2: ______Gender: M F Birthdate:______Address: ______H. Phone ( ) ______W. Phone ( ) ______EE E-mail Address: ______C. Phone ( )______Employer/School:______SSN : ______Stepparent: ______Spouse/Partner: ______Gender: M F DOB:______

Please Specify the Custodial Parent(s):______Please Specify the Person Responsible for the Bill:

Name: ______Gender: M F Birthdate:______Address: ______H. Phone: (______)______W. Phone: (______)______Employer/School:______SSN:______Married: Y N Relationship to Client:______

In Emergency Notify Relative: ______Phone: (______)______In Emergency Notify Friend: ______Phone: (______)______Referred by:______

Primary Insurance Co.: ______(Note: Please be sure to include any alphabetical designator, such as "ZLA," which predecessor is included as part of your Group or ID Number. Some companies will not reimburse with out it. Group #: ______ID #: ______Ins. Phone: (_____)______Name of Insured: ______Relationship to Client: ______Insurance Billing Address: ______Insured's Employer:______Secondary Insurance Co.: ______Group #: ______ID #: ______Ins. Phone: (_____)______Name of Insured: ______Relationship to Client: ______Insurance Billing Address: ______Insured's Employer: ______

The above information is accurate to the best of my knowledge. I have read, understood, and agreed to the Statement of Office Policy, Privacy Practices, Consent to Treatment & Limits of Provider Liability. I authorize my insurance benefits to be paid directly to the provider, acknowledge that I am responsible for any balance due, and I authorize the provider to release any information required to process manual and electronic insurance claims. I have read, understood, and agreed to the Documentation of Understanding Regarding DSHS Insurance Coverage. I will not withhold or delay payment because of any insurance/third party involvement.

Signature of Client: ______Date: ______Signature of Person Responsible for Bill: ______Date: ______