Cape Cod Neuropsychology,LLC
Mary Acunzo, Ph.D
   68 Tupper Road #8   Sandwich, MA 02563
(508) 888-6869  (508) 888-5994 (fax)

Email: info@capecodneuropsychology.com  

INTAKE FORM

PATIENT'S INFORMATION:
Patient Name: Date of Birth (xx-xx-xxxx): --:M/F:
Address : City: State: Zip Code:
Home Phone: Cell Phone: Business Phone:
Email: :
Social Security Number:
Primary Care Physician: Physician's Office Phone:

RESPONSIBLE PARTY:
Name: Address : City: State: Zip Code: :
Home Phone: Cell Phone:
Business Phone: Email:
Relationship to Patient : Second Responsible Party:

PRIMARY INSURANCE INFORMATION:
Insurance Company : Policy Number (and group number):
Name of Insured: Date of Birth (xx-xx-xxxx): --

SECONDARY INSURANCE INFORMATION:
Insurance Company: Policy Number (and group number):
Name of Insured: Date of Birth (xx-xx-xxxx) --

Thank you for taking the time to accurately record your information!

 

FINANCIAL POLICY:

  • Client and Responsible Person is responsible for the entire balance of services performed. If client is paying via insurance, preauthorizations need to be verified before the appointment. Payment (co-pay, co-insurance, deductibles, and testing reimbursement) is due at the scheduled appointment.
  • If Client cancels the scheduled appointment with less than 24 hours notice, $50 will be charged for the time reserved
  • INSURANCE GENERALLY DO NOT REIMBURSE FOR ACADEMIC TESTING OR COMPREHENSIVE REPORTS; IF THESE SERVICES ARE RENDERED, IT WILL BE THE FINANCIAL RESPONSIBILITY OF THE PATIENT/RESPONSIBLE PERSON. IF YOU CHOOSE TO USE YOUR INSURANCE, IT IS IMPORTANT FOR YOU TO KNOW THAT A DIAGNOSIS (FROM DSM-IV) IS REQUIRED WHEN BILLING THE SERVICE.
  • Dr. Acunzo reserves the right to add finance charges, use a collection agency or small claims court in payment is not received in a timely manner, within 90 days of appointment. Attorney services may be utilized. Cancellations need to take place 24 hours in advance. If there is a late cancellation or no show, a $50 charge will be billed for time reserved. On rare occasions due to family illness or inclement weather, Dr. Acunzo may need to close her office. If schools are closed, the office may be. If this occurs, every attempt to reschedule as soon as possible will be made.


I consent to communications (messages left via voicemail or email) at the following:

Phone: Email:

Insurance information, if supplied on this form, will be used to verify benefits, coverage, copays, coinsurances, deductibles and authorize for payment.