Annual Client Insurance Update

Family Service Rochester is in the process of updating our client records. Insurance requires that we have a current signature & updated insurance information on file, on an annual basis. Please  bring to your next scheduled appointment along with a copy of your insurance card. Thank you.

Client Name *:
Client Date Of Birth *:
Address *:
Apt/Suite #:
City:
State/Province:
Zip/Postal Code:
Phone *:
Email *:
Gender:
Patient Relationship To Insured:

Primary Insurance Information
Insurance Company Name *:
Insurance Company Address *:
Insurance Company Phone *:
Policy Number #:
Group Number #:
Subscriber Name:
SS Number #:
Date Of Birth *:
Co-Payment *:
Annual Deductible *:
Amount Met *:
Effective Date *:

Secondary Insurance Information
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone Number:
Policy Number #:
Group Number #:
Subscriber Name:
SS #:
Date Of Birth:
Effective Date:
As a courtesy, our office bills your insurance company; however it is the sole responsibility of the patient to ensure that the bill is paid. We appreciate our clients’ support for prompt resolution of their accounts and will gladly assist in any effort to assure this.

I authorize release to the above named insurance companies, third party payer or Medical Assistance, any information necessary to process this claim. I authorize payment of benefits under the terms of my policy/third party payer to be made directly to Family Service Rochester. I unde rstand i f insurance or any other third party payer does not cover these charges, I can be held financially responsible for payments for all services rendered for the above named client.
Signature Of Person Insured:
Date:

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