Registration Form

Client Information

Last Name

First Name

Middle Initial

Address

City

State

Zip Code

Telephone #

Birthdate

Sex

Relationship Status

Relationship to the Insured

How did you learn about Institute for Change?

Name of IFC Clinician

Insured Information

Last Name

First Name

Middle Initial

Address

City

State

Zip Code

Telephone #

Birthdate

Sex

Relationship Status

Employer Information

Company

Address

City

State

Zip Code

Telephone #

Insurance Carrier

Company

Address

City

State

Zip Code

Telephone #

Group #

ID#

Primary Care Physician

Name

Address

City

State

Zip Code

Telephone #

Emergency Contact

Name

Address

City

State

Zip Code

Telephone #

Relationship

Release of Authorization
I authorize the release of any medical information necessary to my insurance claim(s). I agree that this authorization will cover all medical services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of an original.

Signed (Patient or Representative)

Date

By checking this box I agree that my typed name will constitute my signature.

Assignment of Benefits
I authorize and request payment of medical benefits directly to my provider.

Signed (Patient or Representative)

Date

By checking this box I agree that my typed name will constitute my signature.

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