Nadine Rosen, L.P.C.

                                                      4425 Randolph Rd., Suite 411

                                                              Charlotte, NC 28211

                                                                 704-280-9458

                                                      CLIENT REGISTRATION FORM

CLIENT INFORMATION

Name:_________________________________________________________________________

                   Last                                       First                                     Middle Initial

Birthdate:____/____/____     Age:____      Sex: M (  ) F (  )     SS #_______________________

Marital Status:____________     Employer:____________________________________________

Home Address:__________________________________________________________________

                        Number & Street                                                 Apt. #

                      __________________________________________________________________

                          City                                                  State                         Zip

Home Phone:(       )_____-_____ Work: (       ) _____-_____   Cell:(       )_______-________

Email:_____________________________________________

__________________________________________________________________________________

INSURED INFORMATION

Name of Insured:________________________________________________________________

                     Last                             First                                         Middle Initial

Relationship to Patient_______  Employer of Insured:___________________________________

Birth date:____/____/____     Age:____      Sex: M (  ) F (  )     SS#_______________________

Marital Status:____________ 

Home Address:__________________________________________________________________

                        Number & Street                                                 Apt. #

                      __________________________________________________________________

                          City                                                  State                         Zip

Home Phone:(       )_____-_____ Work: (       ) _____-_____   Cell:(       )_______-________

Email:_____________________________________________

Subscriber ID:_____________________________________     Group #____________________

Deductible:__________   Has it been met? (    )Y  (    )N  Is Authorization needed? (    )Y  (    )N

Insurer Phone # for Verification: (       ) _______-__________

__________________________________________________________________________________

I certify that I (or my dependent) have insurance coverage and assign directly to Nadine Rosen, LPC, all insurance benefits, if any, otherwise payable to me,  for services rendered.  I understand that I am financially responsible for deductibles, co-pays, and missed appointments or appointments not cancelled within 24 hours.  I, hereby, authorize Nadine Rosen to release all information necessary to secure the payment of benefits.  I authorize the use of this signature on all insurance submissions.

Signature:________________________________________          Relationship:_____________

Print Name:________________________________________              Date:_________________