Terry F. Perkins, Ph.D.

License PSY5764 123 Hodencamp Road Suite 106 Thousand Oaks, CA 91360 805.499.2304 Todays date:

PATIENT INFORMATION
Patients last name: Is this your legal name? Yes No Street address: P.O. box: Occupation: City: Employer: State: First: If not, what is your legal name? Middle: Cell Phone ( ) Birth date: / ( / Home phone no.: ) ZIP Code: Employer phone no.: ( Chose office because/Referred to office by (please check one box): Family Friend Close to home/work Other family members seen here: Dr. Other ) Insurance Plan Hospital Age: Sex: M F

Social Security Number

INSURANCE INFORMATION
Person responsible for bill: Is this person a patient here? Occupation: Employer: Birth date: / Yes / No Employer address: Employer phone no.: ( Is this patient covered by insurance? Please indicate primary insurance: Subscribers name: Subscribers ID. no.: Birth date: / Patients relationship to subscriber: Name of secondary insurance (if applicable): Patients relationship to subscriber: Self Spouse Subscribers name: / Child Other Group no.: Policy no.: Group no.: Policy no.: Copayment: $ Yes No Authorization No. ) Address (if different): Home phone no.: ( )

Self

Spouse

Child

Other

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize Terry F. Perkins, Ph.D. or insurance company to release any information required to process my claims. Patient/Guardian signature Date