New Patient Contact Form

To arrange an initial appointment, please complete this form and click the "Submit" button. We'll be in touch.

Information About the Patient

Patient's Name:*

Date of Birth:*

Social Security No.:*

Mailing Address:*

City, State, Zip:*

Cell Phone Number:

Home Phone Number:*

Alternate Phone Number:

E-mail address:*

Information About Your Insurance:

I would prefer to pay out-of-pocket. (If Yes, skip this section and the next and go to the Other Information section)YesNo

Name of Insurance Company:

Insurance Company Billing Address:

City, State, Zip

Mental Health Benefits Phone Number:

Policy No.:

Group No.:

Deductible Amount:

Specialist Co-Pay:

Information About the Insurance Subscriber:

Insured's Name:

Insured's Address: (If different from Patient's)

City, State, Zip

Home Phone Number:

Cell Phone Number:

E-mail Address:

Subscriber's Date of Birth:

Social Security No.:

Other Information

Referred by:

(Optional) Please tell us a bit about the purpose of the visit so we can match you to the most appropriate doctor:

Name, Address and Phone of a relative not living with patient:

By agreeing to each statement below, I

Authorize Michael B. Spellman, Ph.D., PA, to share and obtain information, protected under the legislation known as HIPAA, with my insurance company and primary care physician.*AgreeDisagree

Acknowledge having read, understood and agree to the HIPAA notification and the Terms of Agreement that were either faxed to me or viewed at www.swflpsychology.com.*AgreeDisagree

Agree to keep and be financially responsible for all appointments I make, and to pay for all missed appointments, unless I cancel at least two days in advance.*AgreeDisagree