Chris Chance, Ph.D.
P.O. Box 66 100 High Street, Exeter, NH 03833 (603) 580-1136 connect@DrChrisChance.com
CLIENT INFORMATION
Last Name: ___________________________________________________ Suffix: _________
First Name: _____________________________________________________ MI: ___________
(If under 18 years old) Name of Parent(s): _______________________________________________
Client’s DOB: _______________ Age: _______ SSN#: _________________________________
Mailing Address: ___________________________________________________________________
City: ________________________________________ State: __________ Zip: ___________
Home Phone: ( )_____________ Work: ( )______________ Cell: ( )___________________
Okay to leave message? Y/ N Okay to leave message? Y/ N Okay to leave message? Y/ N
Email - best: ______________________________ additional: _____________________________
Name of Primary Care Physician (PCP): _________________________________________________
Phone Number of PCP: ( ) __________________________________________________________
Emergency Contact: Name:___________________________________________________________ Relationship: _______________________ Phone: ( ) __________________
INSURANCE INFORMATION
Insurance Company (and policy type: PPO? HMO?):________________________________________
ID #: _______________________________________________ Group #: ____________________
Claim Address: _____________________________________________________________________
_____________________________________________________________________
Phone numbers back of Card:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Does your policy cover the following “mental and behavioral health” services at Dr. Chance’s current practice location? (Circle Y or N)
“Initial Evaluation”? Y N “Individual Psychotherapy”? Y N “Family/Conjoint Therapy”? Y N
Outpatient Mental Health Authorization Needed?: Y N Copay: ______ Deductible: ____________
Authorization # for initial sessions(s): ___________________________________________________
Expiration Date: ________ # of Visits: ________ Annual MAX # visits? __________
Is this a “parity” policy (i.e., no annual max for certain “bio-based” diagnoses)? Y N
Relationship to Policy Holder: Self _____ Spouse _____ Child _____ Other ______
Policy Holder’s Name: _______________________________________________________________
Policy Holder’s Address: _____________________________________________________________
_____________________________________________________________
Policy Holder’s DOB: __________________ SSN:________________________________________
Secondary Insurance Company (if applicable): ____________________________________________
ID #: _______________________________________________ Group #: ____________________
Claim Address: _____________________________________________________________________
Phone numbers: _____________________________________________________________________
__________________________________________________________________________________
Outpatient Mental Health Authorization Needed?: Y N Copay: ______ Deductible: ____________
Authorization #: ______________________________________________ Expiration Date: ________
Relationship to Policy Holder: Self _____ Spouse _____ Child _____ Other _________________
Policy Holder’s Name: _______________________________________________________________
Policy Holder’s Address: _____________________________________________________________
Policy Holder’s DOB: __________________ SSN:________________________________________
P.O. Box 66 100 High Street, Exeter, NH 03833 (603) 580-1136 connect@DrChrisChance.com
CLIENT INFORMATION
Last Name: ___________________________________________________ Suffix: _________
First Name: _____________________________________________________ MI: ___________
(If under 18 years old) Name of Parent(s): _______________________________________________
Client’s DOB: _______________ Age: _______ SSN#: _________________________________
Mailing Address: ___________________________________________________________________
City: ________________________________________ State: __________ Zip: ___________
Home Phone: ( )_____________ Work: ( )______________ Cell: ( )___________________
Okay to leave message? Y/ N Okay to leave message? Y/ N Okay to leave message? Y/ N
Email - best: ______________________________ additional: _____________________________
Name of Primary Care Physician (PCP): _________________________________________________
Phone Number of PCP: ( ) __________________________________________________________
Emergency Contact: Name:___________________________________________________________ Relationship: _______________________ Phone: ( ) __________________
INSURANCE INFORMATION
Insurance Company (and policy type: PPO? HMO?):________________________________________
ID #: _______________________________________________ Group #: ____________________
Claim Address: _____________________________________________________________________
_____________________________________________________________________
Phone numbers back of Card:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Does your policy cover the following “mental and behavioral health” services at Dr. Chance’s current practice location? (Circle Y or N)
“Initial Evaluation”? Y N “Individual Psychotherapy”? Y N “Family/Conjoint Therapy”? Y N
Outpatient Mental Health Authorization Needed?: Y N Copay: ______ Deductible: ____________
Authorization # for initial sessions(s): ___________________________________________________
Expiration Date: ________ # of Visits: ________ Annual MAX # visits? __________
Is this a “parity” policy (i.e., no annual max for certain “bio-based” diagnoses)? Y N
Relationship to Policy Holder: Self _____ Spouse _____ Child _____ Other ______
Policy Holder’s Name: _______________________________________________________________
Policy Holder’s Address: _____________________________________________________________
_____________________________________________________________
Policy Holder’s DOB: __________________ SSN:________________________________________
Secondary Insurance Company (if applicable): ____________________________________________
ID #: _______________________________________________ Group #: ____________________
Claim Address: _____________________________________________________________________
Phone numbers: _____________________________________________________________________
__________________________________________________________________________________
Outpatient Mental Health Authorization Needed?: Y N Copay: ______ Deductible: ____________
Authorization #: ______________________________________________ Expiration Date: ________
Relationship to Policy Holder: Self _____ Spouse _____ Child _____ Other _________________
Policy Holder’s Name: _______________________________________________________________
Policy Holder’s Address: _____________________________________________________________
Policy Holder’s DOB: __________________ SSN:________________________________________