Get Tx Wanda Johnson-roberts Client Information

Filling out the TX Wanda Johnson-Roberts Client Information form online is a straightforward process that helps ensure all pertinent details are captured efficiently. This guide will provide you with clear and supportive instructions to complete the form accurately.

Follow the steps to fill out the form correctly

1. Press the ‘Get Form’ button to access the TX Wanda Johnson-Roberts Client Information form and open it in your online editor.
2. Begin by entering the patient's name in the designated field, ensuring accuracy as this will be used throughout the documentation.
3. In the 'Referral' section, include the name of the individual or organization that referred the patient, if applicable.
4. Fill in the mailing address, phone number, city, state, and zip code to ensure proper communication.
5. Provide the patient's employer name and their birth date in the respective fields.
6. Input the work or cell phone number to facilitate contact, and indicate the marital status by circling one of the options: married, single, or other.
7. Fill in the social security number and the name of the spouse or guardian along with their phone number.
8. Indicate whether the contact person is a spouse or guardian by circling the appropriate option.
9. Include the spouse or guardian's employer and list the names and ages of any children.
10. Designate an emergency contact along with their phone number and relationship to the patient.
11. For primary insurance, circle the appropriate option indicating whether the insured is self, spouse, parent, or other.
12. Complete the name of the insured, their date of birth, insurance company, identification number, and group/account number.
13. List the insurance company phone number and the employer of the insured.
14. Review the statement regarding payment due at the time services are rendered and provide your signature along with the date.
15. Review and fill out the assignment and instruction for direct payment, including signatures where required.
16. Complete the confidentiality and release of information section as needed, and ensure all necessary consents are indicated.
17. Finally, provide a signature on the appointment policy agreement, date it, and make sure to list any current medications.
18. Once all sections are complete, ensure to save your changes. You may also download, print, or share the form as necessary.

Complete your TX Wanda Johnson-Roberts Client Information form online today to ensure a smooth and efficient process.