Patient Registration Form

Please fill out and submit the form below prior to your appointment date / time. You may also download and print the form to manually fill it out and bring it with to your appointment using this link: DOWNLOAD FORM


PATIENT INFORMATION

 

    

RESPONSIBLE PARTY INFORMATION

 

  

EMERGENCY INFORMATION

 

  

 

I understand and agree, I am a private patient, personally responsible for payment of service rendered at Psychiatric Services of Prescott. This office does not file insurance claims. If I am a Medicare beneficiary, I will not expect claims to be filed or reimbursements to be made by Medicare or my secondary insurance, as Psychiatry Services of Prescott has opted out of Medicare.  By signing this I am knowingly receiving services from an opted out provider . If my account should ever be in default, I will be responsible for all legal/collection fees in addition to the balance due.

I understand payment is due at the time of service. Psychiatric Services of Prescott will not bill insurance carriers, but will provide a detail statement to be submitted by the patient upon request. In the event that my insurance carrier requests additional information in order to process my claims, I authorize the release my information.

I certify that the above information is true and correct to the best of my knowledge.