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Client Information Sheet
Phone:
Insurance Co.:
Policy #:
Customer Service Phone:
Mental Health Phone:
DO YOU HAVE SECONDARY INSURANCE?
Who is the Insured:
Yes
Birth Date:
Policy #:
Customer Service Phone:
Authorization #:
no
Work Phone:
Insurance Co.:
Name of EAP:
or
SS#:
Employer of Insured:
DO YOU HAVE EAP?
Group #:
Group #:
Mental Health Phone:
Yes
or
no
Phone # of EAP:
Sessions Authorized:
From
To
I authorize the release of any medical or other information necessary to process...
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