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Insurance/Financial Form (Web)

Community & Family Resources
Phone 515-576-7261
Fax 515-955-7628
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Date
* Employment Status
Employer
* Months Employed in the last 6 months
* Occupation
* Monthly Income
Annual Income
* Primary Income Source
* Other Source of Income(1)
Other Source of Income(2)
* Number of Children (children age 17 or less (birth, adopted, or stepchildren)
* Number of Children that have lived with the patient last 6 months
* Are any of your children living with someone else due to protection order?
* Marital Status
* Living Arrangement
Slide subject to change based upon income verification
* Client Signature
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
Ability To Pay
Household
Income
Monthly
Yearly
Calculate
Result
  % pay
Sliding Fee Percentage
Income Verified?
Yes   No    
If no, reason
Income Verified By
Additional Comments    explain employment and insurance situation
Responsible Party    (use if the client is a minor)
Name:
Address:
Address Line 2:
City: State: Zip Code:
Country:
Phone: (Home)
  
(Business)
   (Cell)
  Message may be left at above phone number?    
  Yes        No   Yes        No   Yes        No
Relationship:
Email:
* Insurance Type
Medicaid #
Medicare #
Primary Insurance Provider
Name of Primary Subscriber
Primary's Date of Birth
Client's relationship to Insured
Group #
Policy ID
* Does insurance cover Substance Abuse Treatment
Secondary Insurance
Name of Secondary Subscriber
Secondary's Date of Birth
Client's relationship to Insured
Group #
Policy/ID #
Tertiary Insurance
Name of Tertiary Subscriber
Tertiary's Date of Birth
Client's relationship to Insured
Group #
Policy/ID #
* Expected Payment Source
* Other Payment Source (1)
Other Payment Source (2)
Client Signature
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
Income Verification
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Scan/Change Document

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