Michael Ollom, LISW Live!, LLC

                      

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Appointment Date: Pick a date

                       Patient Information

First Name:   Middle Initial:     Last Name:

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You are scheduled to see Michael Ollom, LISW Live!, LLC.

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Date of Birth: Set your date of birth   Social Security Number:

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Patient Employer:  Work Phone:

Primary Care Doctor:  Phone Number:

                       Payment Information

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I hereby authorize Michael Ollom, LISW Live!, LLC to use the above credit card information to cover

any copays, coinsurance or self-pay amounts or amounts not covered by my insurance for payment.

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                       Responsible Party Information

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Phone:  Alternate Phone:   Relationship:

 

                       INSURANCE INFORMATION


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Primary Insurance Co.   Phone:

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ZIP Code:   Name of Insured:   Insured Id #:

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Secondary Insurance Co.   Phone:

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Is this an Employee Assistance Program Visit (EAP) ?   Auth #:

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If you will be using your commercial insurance once your EAP visits have been exhausted, please fill out insurance information above.

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                       ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I have been presented with a copy of Michael Ollom, LISW Live!, LLC's Notice of Privacy Policies, detailing how my

information may be used and disclosed as permitted by federal and state law. I understand the contents of the Notice, and I request

the following restriction(s) concerning the use of my personal medical information:

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