James M. Read, Ph.D.
Clinical Psychologist
http://www.jread.com
2304 North Cole Road, Suite B -- Boise, Idaho 83704-7371 -- Telephone (208) 377-0271 -- Facsimile (208) 377-3134
Electronic mail -- jread@jread.com

Please help us with some financial and insurance related information so we can better serve you. This
information will be used to help us file your insurance claim. Thanks!

Today's Date: _________________

Patient Information		Financially Responsible Person
Name: __________________________________		Name: __________________________________
Address: ________________________________		Address: ________________________________
City/State/Zip: ____________________________		City/State/Zip: ____________________________
Marital status: ______ DOB: _________________		Home phone #: ( ) _________________________
Gender: ______ SS#: _______________________		Social Security #: __________________________
Home phone #: ___________________________		Employer: _______________________________
Employer: _______________________________		Address: ________________________________
Address: ________________________________		City/State/Zip: ____________________________
City/State/Zip: ____________________________		Occupation: ______________________________
Occupation: ______________________________		Business phone #: ( ) _______________________
Business phone #: ( ) _______________________
Physician's name: __________________________		Referred by: _____________________________ Name Relationship
Address: _________________________________		Address: ________________________________
City/State/Zip: _____________________________		City/State/Zip: ____________________________
Phone #: ( ) _______________________________		Phone #: ( ) ______________________________

Insurance Company Information
( ) Blue Cross ( ) Regence Blue Shield ( ) Self pay ( ) Other

Insurance Company Name: _______________________________ SS #: ____________________________
Address: ________________________________________ Group #: ______________________________
City/State/Zip: __________________________ Subscriber's name: ________________________________

Please note: All professional services rendered are charged to the patient. The patient is responsible for all fees, regardless of insurance coverage. We would
appreciate receiving payment for services at the time they are rendered. If your insurance company covers psychological services we will be happy to
submit the claim for you if you like. I understand that I am financially responsible for payment for services rendered to the above named patient.

Date: _______________ Signature of financially responsible person: ______________________
Revised March 24, 2003