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Therapy for adults with ADHD, OCD, anxiety, and depression

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Patient full name*

Date of birth*

Month

Day

Year

Street address

City

State

ZIP code

Mobile phone

Email*

Social Security number*

Marital status

Employer

Occupation

Primary care physician

Specialist physician

Who referred you to this office?

Medical history / reason for visit*

HIPAA Notice and Privacy Practices: Please review the privacy notice and authorization language provided by the practice before acknowledging below.

I acknowledge that I have reviewed and understand the HIPAA Notice of Privacy Practices.

I authorize the assignment of applicable medical benefits and understand that payment in full may be expected at the time of service.

Patient or representative name*

Date*

Month

Day

Year

Insurance company

Name of insured

Relationship to patient

Policy number

Group number

Emergency contact name*

Relationship to patient*

Emergency contact phone*

Insurance and payment authorization notes*

katherine@drkkilgore.com

13405 Folsom Blvd #220,
Folsom, CA 95630

Fees & Insurance

©2020 by Katherine M Kilgore, PhD.

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