Kinta M. Parker, PhD

CLIENT INFORMATION

Name

Birth Date

____ Male
____ Female

Social Security Number

Street Address

City

State

Zip Code

School

Grade

Employer

Work Phone

Referred by

Primary Physician

Home Phone

Reason for Appointment

Cell Phone

Email Address

Emergency Contact Name & Relationship

Emergency Contact Address

Emergency Contact Phone

Guardianship Information (if applicable)

INSURANCE INFORMATION (Please provide your insurance card to be copied)

Insurance Provider

Member's Name

Birth Date

Employer

Group Number

Policy Number

Client's Relationship to Member

Person Responsible for Bill and Address, if different from above

Your Signature

Acknowledges:	Accuracy of above information and financial responsibility to pay any balance and fees for attorney if required for account collection Receipt and agreement to abide within Dr. Parker's Outpatient Service Contract (revised 1-1-04) Receipt of HIPAA and State of Alabama policy and practices to protect your health information
Authorizes:	Consent for me or my minor child to be evaluated and/or treated by Dr. Kinta Parker Dr. Parker to release information required to process my insurance claim and for insurance benefits to be paid to Dr. Parker
_____________________________________________ Printed Name of Client/Guardian		____________________________ Date
_____________________________________________ Signature of Client/Guardian		____________________________ Relationship to Client (if not client)
_____________________________________________ Witness		____________________________ Date