Patient Information Form

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)

Responsible Party/Parent/Guardian

Please do not add spaces. Example: 123456789

Financial Responsibility Statement
Jennifer 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

Cancellations

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***

   
Intial Interview $185`
Individual Psychotherapy 50-60 min. $165
Individual Psychotherapy 40-45 min. $140
No Show/ Late Cancellations $65

 

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.

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