Blue Mountain Psychology, PLLC
Dr. Jameson C. Lontz
1624 W. Dean Avenue, Spokane, WA 99201
Phone: (509) 939-6863; Fax: (509) 464-6463; Email: [email protected]
Please complete as much information as possible
including a phone number for the insurance company. Thank you.
Today’s Date:
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Patient Address:
Patient’s home phone:
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Male Female
Other ___________
Race:
Referral reason:
Name of referee:
Referee NPI#:
Primary Care Physician (PCP):
Primary insurance carrier:
Contract #:
Subscriber name:
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First
Last
Middle
Date verified (Staff only):
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Secondary insurance (inc. auto):
Contract #:
Subscriber name (if different):
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Date verified (Staff only):
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Patient Name:
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Middle
Patient’s work phone:
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Patient’s SSN: ____-___-_____
Patient’s Date of Birth
(DOB):
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Email:
Patient’s cell phone:
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Previous patient?
Yes No
Dates: __________
Ethnicity:
Referee phone number:
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Referee address:
PCP phone number:
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Referee fax number:
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Insurance phone#:
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Group#:
Subscriber’s Date of Birth:
___/___/_____
Claims mailing
address:
Contact person:
Call notes:
Insurance phone#:
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Group#:
Subscriber’s Date of Birth:
_____/_____/_______
Claims mailing
address:
Contact person:
Call notes:
PCP address:
Employer:
Employer:
Authorization #:
Services Provided (Staff only)
ICD-9:
__________ __________ __________ __________
DSM-IV-TR: Axis I ________ Axis II _______ Axis III _______ Axis IV _______ Axis V ___
90791 ____/____/20____
90832 ____/____/20____
90834 ____/____/20____
96101 ____/____/20____
96118 ____/____/20____
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