Sid Kramer, LCSW
Patient Registration Form


Patient Name_____________________________________________________________________

Street Address____________________________________________________________________

City___________________________State_______Zip Code__________

Email Address____________________________________________________________________

Home Phone______________________________Cell Phone______________________________

Preferred mode of contact,
Home Phone______Cell Phone_____Email____Text_______Date of Birth____________

Sex: M ___F___Marital Status____Patient Social Security #_________________________________

Responsible Party and DOB __________________________________________________
Relationship to Pt. : ________

Insurance Plan_____________________________Employer_______________________________

Policy #___________________Group #_______________________
Policy Holder’s Name and DOB_______________________________________________________

Permit to Treat: I hereby voluntarily consent to, permit and authorize,
Sid Kramer, LCSW to administer therapeutic treatment and to perform
procedures and tests deemed advisable during my care.
Release of Information: I authorize the release of information for insurance
claim purposes.
Assignment of Benefits: I authorize payment directly to Sid Kramer, LCSW
for services rendered. I understand I am responsible for any portion of my
bill not covered by insurance.

Signed_____________________________________Date_________________________________