PATIENT INFORMATION FORM
Jerri L. Whiting, Ph.D. ♦ Jennifer Lowe, LCSW
632 SE 4th Street • Lee’s Summit, MO 64063 • Phone: (816) 554-7750
EMERGENCY CONTACT: (OTHER THAN SPOUSE OR ABOVE INFORMATION)
Financial Responsibility StatementJennifer Lowe, LCSW
We will file your primary and/or secondary insurance as a courtesy to you. Any co-payments,
deductibles or non-covered charges are the responsibility of the patient. Payment is due at the time services are rendered
unless prior arrangements have been made.
Primary Insurance Carrier
A full 24 hour notice is required for all cancellations.
Otherwise a fee of $65 will be charged for the missed appointments.
This charge will be the patient's responsibility.
*** FEE SCHEDULE***
It is your responsibility to advise the office of all insurance information
or any changes in insurance, address or telephone number
I authorize my doctor and his/her staff to act as my agent in helping me to obtain the fullest payment from my insurance company
I authorize payment directly to Whiting & Associates, LLC, and the release of information to all of my insurance carriers.
I permit this authorization to be used in place of the original. I understand the office policy and agree to pay my co-pay
or deductible at the time of service.
In lieu of filing my insurance, I agree to pay the self-pay cash rate
for each visit in full at the time of service. I understand that the
cancellation policy still applies.
Copyright © 2019, Whiting & Associates, LLC