Patient's First Name:
Patient's Last Name:
Contact Number:
Email Address:
Date of Birth:
Please fill in all information below.  
The following information can be found on your insurance card.
Insurance Company:
Policy ID Number:
Group Number:
Telephone number for Mental
Health/ Behavioral Health or M.H.
Telephone number for Benefits/
Customer Service/ Providers:
Please complete the following section if the insurance is under a different  name  than
Policy Holders Name:
Policy Holders DOB:
Policy Holders Employer:
Please leave any additional comments below
We require 48 hours notice before your appointment to verify new or changed insurance. This allows us time
to verify your co pay and check your deductibles so we may collect the correct amount.
If you are seen by the doctors and
your insurance does not cover your
claim, the balance is the responsibility
of the patient.  This is true even if the
preliminary check with insurance
company by us indicates that you are
covered and you are seen with the
expectation that we will bill your

Until the claim is completed by the
insurance, we can not positively know
if you are covered.

Some services such as phone
consultations with other providers,
review of records, rush prescription
refills, no-show charges, cancellation
fees, form filling, reports etc. are often
NOT a reimbursable expense. If these
services are used or requested by
you, you are responsible for their
charge. Your insurance company will
not pay for most of these.
Houston Adult Psychiatry