Mona A. Kalhor, PSY-D, MBA
Licensed Forensic and Clinical Psychologist
Cell: (954) 732-1103 - e-mail: firstname.lastname@example.org
Patient’s Full Name: SS#:
Date of Birth: Sex: F M Age: Phone:
Drivers License #:
Family Physician: Referred by:
Person to Contact in Emergency: Phone:
Insured’s Primary Ins, C: ID: NO: Group NO:
I attest that I read the limits of confidentiality and treatment contract as well as
Office Billing and Insurance policy:
1- I authorize use of this form on all of my insurance submissions.
2- I authorize the release of information to my insurance company(s).
3- I understand that I am responsible for the full amount of my bill for service provided.
4- I authorize direct payment of my service provider.
5- I hereby permit a copy of this to be used in place of any original.
6- It is your responsibility to pay any deductible (if insurance accepted) at the time of service.
7- There will be a $50 for a return check.
8- There is a 48 hrs cancellation policy which requires that you cancel you appointment 24 hours in advance between the hours of 8 am- 4 pm, Monday through Friday to avoid being charged $50 for no show.