Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

DOB

MM

DD

YYYY

Male

Female

Responsible Party

First Name

Last Name

Phone

(###)

###

####

Primary Insurance Carrier

Insurance Co. Name

ID #

Group #

Insured Name

First Name

Last Name

Patient Relationship

Self

Spouse

Child

Phone on back of insurance card

(###)

###

####

Signature

Today's Date

MM

DD

YYYY

Credit Card/Billing Information

Please be aware that your therapist is only compensated once you or your insurance company makes a payment on your account. This is why we charge a $50 fee when you do not show for your scheduled appointment time or do not cancel within 24 hours.

*I authorize Gabriel Group Counseling, LLC, to charge the portion of my bill that is my financial responsibility to the following credit or debit card:

Visa

Mastercard

American Express

Discover

Debit Card

Credit Card Number

Expiration Date

MM

DD

YYYY

CVC

Cardholder Name

First Name

Last Name

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Signature

I (we), the undersigned, authorize and request Gabriel Group Counseling, LLC, to charge the card, indicated above, for the balances due for services rendered.

Client name

First Name

Last Name

Client/Responsible Party Signature

Consent for Treatment: By signing above, I as the patient or legal guardian of, authorize the Insurance Carrier to make checks for medical expenses due me payable to the attending staff or associated practice. I also authorize the release of any infom1ation regarding treatment to the Insurance Carrier. I further understand that I am responsible for all medical expenses and agree to pay any expenses not covered by the above Insurance Carriers. I understand that after my primary carrier has paid or rejected payment, I am responsible for the remaining balance and that billing my insurance is done of contractual obligation for participating carriers and is done only as a courtesy for other non-participating carriers.

Patient Registration

To update your information, view your account, and to make payments online, visit: www.ncdsinc.com and click on “Patient Login.”

Credit Card/Billing Information

Please be aware that your therapist is only compensated once you or your insurance company makes a payment on your account. This is why we charge a $50 fee when you do not show for your scheduled appointment time or do not cancel within 24 hours.

Gabriel Group Counseling