New Patient short Form (#14)

Client Confidential Information Form

Insurance Information

Please attach a copy of your state picture identification AND a copy of your insurance card here. If not,
please attach under the messaging tab in the Patient Ally Portal, via our secure email address at: OR attach under the Book Appointment tab on our web site at for any difficulties, please call our office: 833-583-4778.

INSURANCE AUTHORIZATION AND ASSIGNMENT: I understand that I am responsible for all charges ncurred by me and all charges not allowed by my insurance company. I authorize the release of medical information necessary to process my claims. I authorize payment of any assigned medical benefits to my provider directly.

Legal Representative of Patient

If the patient is not a minor or does not require legal representation, please skip this part.

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