MSM Counseling Services

ADDRESS: 180 Mineral Platteville, WI 53818 USA EMAIL: msmstaff@msmcounselingservices.com TEL: 414 433 3521 FAX: 414 293 5508

Patient Registration Form

Patient Information

Patient Name

Spouse/Significant Other Name

Date of Birth

Social Security Number

Marital Status

Gender

Street Address

City, State, Zip

Phone Number

Cell Phone Number

Patient Email

Patient Employer – Address – Phone

Billing Information (If different)

Responsible Party for Bill

Billing Phone Number

Billing Address

Billing City, State, Zip

Responsible Party's Employer

Responsible Party's Employer Address

Nearest Friend/Relative (not at same address) & Relationship

Address & Phone of Friend/Relative

Primary Insurance

Policyholder Name

Policyholder DOB

Insurance Company

Insurance Address

City, State, Zip

Insurance ID

Group #

Medicare #

Medical Assistance #

Secondary Insurance

Policyholder Name

Policyholder DOB

Insurance Company

Insurance Address

City, State, Zip

Insurance ID

Group #

Medicare #

Medical Assistance #

Self-Pay and Authorization

Self-Pay Fee

Per (Minutes)

Patient Endorsement

Date