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Patient Registration Form

Personal Information

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Main Phonenumber
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Secondary Phonenumber
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Marital Status:
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Emergency Contact Phonenumber
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(For Patients Under 18)

Mother’s Name
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Mother’s Name
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Father’s Name
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Father’s Phonenumber
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(If patient does not reside with mother or father):
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  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
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Field is required!
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Main Phonenumber
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Invalid phonenumber!
Secondary Phonenumber
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Insurance Information

**A copy of your insurance card is required, or you will be a self-pay patient. We do require all fields to be filled out, as our billing is off-site. Please note that we do not file to secondary or tertiary insurances, Medicaid, or Medicare**
Insurance Company Name
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Insurance Phonenumber
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PCA Financial Policies

The following is a statement of our Financial Polices which we require you to read, initial by each statement, and sign prior to receiving any treatment from our providers:
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(A) Thank you for choosing Psychiatric and Counseling Associates, LLC for your care. Please understand that payment of your bill is considered a part of your treatment. Insurance is a contract between you and your insurance company. It is your responsibility to know your insurance policy benefits. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, or other matters regarding reimbursement.
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