Internet Addiction Recovery Program APPLICATION ... - HEAL

Internet Addiction Recovery Program
MEDICAL INSURANCE INFORMATION
ID NUMBER – Copy from your health insurance identification card
GROUP NUMBER:
IDENTIFCATION NUMBER:
PATIENT INFORMATION
PARTICIPANTS FULL LEGAL NAME (Last, First, Middle)
Sex
Male
Female
SOCIAL SECURITY
NUMBER (Optional)
/ /
PATIENT IS: Member Spouse Child Other. Please explain relationship:
IF CLAIM IS FOR CHILD 19 OR OLDER‐IS CHILD: A full‐time student Yes No Disabled Yes No
DATE OF BIRTH
Month Day Year
| |
PAYEE:
MAKE PAYMENT TO THE PROVIDER (HOSPITAL, DOCTOR ETC.), OR
MAKE PAYMENT OT MEMBER, THE PROVIDER HAS BEEN PAID
MEMBER INFORMATION
MEMBERS FULL LEGAL NAME (Last, First, Middle)
CURRENT ADDRESS:
IF COVERAGE IS THRU YOUR
EMPLOYER, PROVIDE
Group (Employer name)
Sex
Male
Female
SOCIAL SECURITY
NUMBER (Optional)
/ /
DATE OF BIRTH
Month Day Year
| |
HOME PHONE:
(____)
WORK PHONE:
(____)
OTHER INSURANCE INFORMATION
Are there OTHER medical benefits available to you, your spouse, or your dependents form OTHER Group Insurance, including OTHER
employers, Labor or Professional Organizations, schools Yes No
POLICY HOLDER NAME:
POLICY HOLDER IS: Member Spouse Child OTHER, please explain relationship
INSURANCE CARRIER NAME: POLICY NUMBER: EFFECTIVE DATE:
SOCIAL SECURITY NUMBER
(Optional)
/ /
ADDRESS:
PHONE NUMBER:
(____)
RELEASE OF INFORMATION: I certify that the above information is correct to the best of my knowledge. I understand that use or
disclosure of individually identifiable health information, whether furnished by me or obtained from other sources such as medical
providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability and Accountability Act
of 1996).
A copy of the front and back of the medical insurance card is attached to this application.
Sign
HERE ____________________________________________________________________ Date ______________________________
Signature of Member
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reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189
restart@netaddictionrecovery.com | www.netaddictionrecovery.com